FACTORES PREDICTIVOS DE RESPUESTA AL TRATAMIENTO

Transcription

FACTORES PREDICTIVOS DE RESPUESTA AL TRATAMIENTO
DEL VHC EN PACIENTES COINFECTADOS POR EL VIH
Antonio Rivero Juárez
Directores de Tesis
José Peña Martínez / Antonio Rivero Román
TITULO: FACTORES PREDICTIVOS DE RESPUESTA AL TRATAMIENTO DEL
VHC EN PACIENTES COINFECTADOS POR EL VIH
AUTOR: ANTONIO RIVERO JUAREZ
© Edita: Servicio de Publicaciones de la Universidad de Córdoba.
Campus de Rabanales
Ctra. Nacional IV, Km. 396 A
14071 Córdoba
www.uco.es/publicaciones
[email protected]
Agradecimientos:
Al Profesor D. José Peña Martínez por su contagioso entusiasmo en la
investigación y su envidiable inquietud científica.
A mis compañeros de la de la Unidad Clínica de Enfermedades Infecciosas
del Hospital Universitario Reina Sofía de Córdoba, por su dedicación y
entrega.
A mis compañeros del Instituto Maimonides de Investigación Biomédica
de Córdoba (IMIBIC) por su cariño, apoyo y confianza depositados en los
trabajos que he realizado.
Al Grupo para el Estudio de las Hepatitis Viricas (HEPAVIR) de la
Sociedad Andaluza de Enfermedades Infecciosas (SAEI), ejemplo de
cooperación e investigación, por su inestimable colaboración.
A mis compañeros del Laboratory of Molecular Antibodies de la Food and
Drug Administration (FDA) de EEUU: Venkateswara Sinhadri, Quing Zou,
Milarova Bratislova, y en especial a Francisco Borrego por su cariño y
acogida durante mi estancia.
A mi familia por su constante apoyo y motivación. Con ellos ha sido más
fácil la realización de este trabajo.
Por último a mi mejor amiga Alejandra, por su comprensión ante tantas
horas dedicadas a la investigación, que nos han privado de pasar mas
tiempo juntos.
A mis abuelos
Ana, Antonio, Eduardo y Juana
“About 80 percent of chronic, post-transfusion Non-A Non-B Hepatitis
(NANBH) patients from Italy and Japan had circulating HCV antibody; a
much lower frequency (15 percent) was observed in acute, resolving
infections. In addition, 58 percent of NANBH patients from the United
States with no identifiable source of parenteral exposure to the virus were
also positive for HCV antibody. These data indicate that HCV is a major
cause of NANBH throughout the world”
Kuo G et al. Science. 21 de Abril de 1989
INDICE
Abreviaturas…………….
Summary…………………
Introducción…………….
1. Genoma y ciclo biológico del virus de la Hepatitis C (VHC).
1.1.
Características Genómicas del VHC
1.2.
Ciclo biológico
1.2.1 Anclaje y fusión a la membrana del hepatocito
1.2.2 Translación y replicación viral
1.2.3 Ensamblaje y liberación de los virones
2. Aspectos epidemiológicos de la infección por el VHC
3. Tratamiento frente a la infección crónica por el VHC en el paciente
coinfectado por el VIH
3.1.
Objetivos del tratamiento
3.2.
Tratamiento con interferón pegilado más ribavirina
3.3.
Uso de Fármacos de acción directa en pacientes coinfectados por
VIH y Genotipo 1 del VHC.
3.3.1. Uso de Boceprevir
3.3.2. Uso de Telaprevir
3.3.3. Limitaciones del tratamiento con Telaprevir y Boceprevir
3.3.4. Importancia de la identificación de subgrupos de pacientes con
alta probabilidad de alcanzar RVS con IFN-Peg/RBV.
4. Predicción de la respuesta al tratamiento con IFN-Peg/RBV
4.1.
Factores basales de respuesta al tratamiento del VHC
4.2.
Cinética viral del VHC
Referencias…………….
Objetivos…………….
Publicaciones presentadas…………….
1. Twelve week post-treatment follow-up predicts sustained virological
response
to
pegylated
interferon
and
ribavirin
therapy
in
HIV/hepatitis C virus co-infected patients.
2. Association between the IL28B genotype and hepatitis C viral
kinetics in the early days of treatment with pegylated interferon plus
ribavirin in HIV/HCV co-infected patients with genotypes 1 or 4
3. LDLr Genotype Modifies the Impact of IL28B on HCV Viral
Kinetics after the First Weeks of Treatment with PEG-IFN/RBV in
HIV/HCV Patients
4. The IL28B effect on HCV kinetics of among HIV patients after the
first weeks of Peg-IFN/RBV treatment varies according to HCV-1
subtype
5. Differences in HCV Viral Decline between Low and Standard-Dose
Pegylated-Interferon-alpha-2a with Ribavirin in HIV/HCV Genotype
3 Patients
6. Baseline risk factors for relapse in HIV/HCV co-infected patients
treated with PEG-IFN/RBV
7. Atazanavir-Based Therapy Is Associated with Higher Hepatitis C
Viral Load in HIV Type 1-Infected Subjects with Untreated Hepatitis
C
Discusión…………….
1. Bloque I: Predicción de respuesta al tratamiento tras la finalización
del mismo: evaluación del valor predictivo positivo sobre RVS de
la semana 12 tras finalización del tratamiento.
2. Bloque II: Evaluación de la influencia de los factores genéticos
IL28B (rs129679860) y LDLr (rs14158) en la respuesta al
tratamiento mediante el estudio de la cinética viral durante las
primeras semanas del mismo.
a.
Efecto de IL28B (rs129679860)
b.
Efecto de LDLr (rs14158)
c.
Efecto de IL28B en los genotipos 1a y 1b del VHC
3. Bloque III: Evaluación de la respuesta al tratamiento del VHC
genotipo 3
con distintas dosis de IFN-Peg/RBV mediante el
estudio de la cinética viral durante las primeras semanas del
mismo.
4. Bloque IV: Estudios sobre factores basales predictivos de respuesta
al tratamiento.
a.
Factores basales asociados a VR del VHC en pacientes
tratados con IFN-Peg/RBV coinfectados por el VIH
b.
Influencia de los fármacos integrantes del ART en la carga
viral basal del VHC
Conclusiones…………….
Anexo I: Otras publicaciones derivadas del trabajo del doctorando
Anexo II: Estancias en centros internacionales derivadas del proyecto de
tesis doctoral
Anexo III: Premios de investigacion conseguidos por el doctorando
Anexo IV: Proyectos financiados mediante convocatoria pública como
investigador principal derivados del proyecto de tesis
Anexo V: Capítulos de libros derivados del proyecto de tesis doctoral
Anexo VI: Patente derivada del proyecto de tesis doctoral
Abreviaturas:
AEMPS: Agencia Española de Medicamentos y Productos Sanitarios
ARN: Ácido ribonucleico
ATV: Atazanavir
BOC: Boceprevir
BOC+IFN-Peg/RBV: Boceprevir más interferón pegilado y ribavirina
BR: Bilirrubina
BV: Biliverdina
CD4: Linfocito T con cúmulo de diferenciación 4
CD81: cúmulo de diferenciación 81
CL: Cuerpos lipídicos
CLD-1: Claudina 1
dL: decilitro
FAD: Fármacos de acción directa frente al Virus de la Hepatitis C
g: gramo
GAGs: Glicosaminoglicanos
HLA-C: Antígeno Leucocitario Humano tipo C
IC: Intervalo de Confianza
IFN-Peg: Interferón pegilado
IFN-Peg/RBV: Interferón pegilado más ribavirina
IFN: Interferón
IL28B: Interleuquina 28B
IMC: Índice de Masa Corporal
IPs: Inhibidores de la proteasa del Virus de la Hepatitis C
IRES: Región de internación al ribosoma
Kb: Kilobases
Kg: Kilogramo
KIR: Killer immunoglobuline-like receptor
LDG: Grupo de dosis bajas de tratamiento
Lipoproteina de baja densidad: LDL
Lipoproteina de muy baja densidad: VLDL
Log10: Logaritmo en base 10
mg: miligramo
mL: mililitro
NK: Células Natural Killer
NPC1L1: Niemann-Pick C1-like 1 cholesterol receptor
NR: No respuesta (Null-Responder)
OCL-1: Ocludina 1
PL: Partícula Lipoviral
RBV: Ribavirina
RE: Retículo endoplasmático
Receptor de la Lipoproteina de baja densidad: LDLr
RFT: Respuesta Fin de Tratamiento
RVPc: Respuesta Viral Precoz completa
RVPp: Respuesta Viral Precoz parcial
RVR: Respuesta Viral Rápida
RVS: Respuesta Viral Sostenida
SDG: Grupo de dosis estándar de tratamiento
SIDA: Síndrome de la Inmunodeficiencia Humana Adquirida
TAR: tratamiento antirretroviral
TPV: Telaprevir
TPV+IFN-Peg/RBV:Telaprevir más interferón pegilado y ribavirina
UGT1A1: UDP-glucuronosyltransferase 1 family 1
UI: Unidades Internacionales
VB: rebote viral (Viral Breakthrough)
VHC: Virus de la Hepatitis C
VIH: Virus de la Inmunodeficiencia Humana
VPP: Valor Predictivo Positivo
W12: semana 12 tras finalización del tratamiento con interferón pegilado
más ribavirina.
µg: microgramo
Summary
The aim of this work was to study and identify factors associated with
HCV treatment response using pegylated-interferon plus ribavirin (PegIFN/RBV) in HIV co-infected patients. The results of the present research
have been published as seven different papers, which are summarized here.
The duration of HCV treatment varies according to HCV genotype. While
the duration of treatment for patients infected with HCV genotypes 2 or 3
(higher responders) is 24-48 weeks, length of treatment for patients bearing
HCV genotype 1 or 4 (lower responders) can be up to 72 weeks. Patients
with undetectable serum HCV RNA achieve end-of-treatment response
(ETR). If, after twenty-four weeks (W24), HCV viral load remains
undetectable, the patient achieves sustained virological response (SVR), the
gold standard of healing. Meanwhile, if HCV RNA is detected again during
these 24 weeks, the patient shows a viral relapse (VR). In monoinfected
HCV patients, a relapse generally occurs soon after successful therapy has
been discontinued, and several studies have shown that testing HCV
monoinfected patients for serum HCV RNA 12 weeks after completion of
standard Peg-IFN/RBV therapy (W12) is predictive of SVR. Furthermore
HIV-associated immune disorders could theoretically impair the definitive
clearance of HCV infection after HCV therapy, so altering the timing of an
HCV relapse. For these reasons, there could be a difference between HCV
and HIV/HCV co-infected patients. We performed two prospective studies
to evaluate these points which included HIV/HCV co-infected patients who
achieved ETR.
Firstly, we evaluated the positive predictive value (PPV) of the W12
assessment and whether it is as informative as one at W24. Of the 104
patients included, 83 (79.8%) had SVR at W24, and 21 (20.2%) had VR.
At W12, HCV RNA was undetectable in 83 (79.8%) patients and all of
these had SVR. An undetectable HCV RNA at both W12 and W24 had a
100% PPV [95% confidence interval (CI) 96.5%–100%] for SVR. We
concluded that undetectable HCV RNA at W12 following treatment has a
high PPV for SVR and that testing for HCV RNA at this moment may,
therefore, be considered an appropriate point for identifying SVR or relapse
in HIV/HCV co-infected patients receiving treatment with Peg-INF/RBV.
Secondly, we used the same population to analyze the factors associated
with VR. Patients who relapsed showed the following: higher baseline
HCV RNA levels (bivariate analysis: p = 0.012; multivariate OR [95%C]:
2.17 [1.2-7.9]); body mass index (BMI) >25 kg/m2 (bivariate analysis: p =
0.034; multivariate OR [95%C]: 1.6 [1.1-2.7]); significant liver fibrosis
(bivariate analysis: p= 0.001; multivariate OR [95%C]: 5.97 [2.1-11.9]);
had been diagnosed with acquired immunodeficiency syndrome (AIDS)defining criteria in the past (bivariate analysis: p = 0.001; multivariate OR
[95% CI]: 3.86 [1.92-10.23]); and bore HCV genotypes 1/4 (bivariate
analysis: p = 0.046 multivariate OR [95% CI]: 1.97 [1.01-5.91]) when
compared with those who achieved SVR. We found that VR can be
accurately predicted in HIV/HCV co-infected patients on the basis of the
risk factors, which can be identified before treatment.
Additionally, it was evaluated the influence of Atazanavir based
antiretroviral HIV treatment on HCV baseline viral load. We identified that
HIV ATV-based therapy was associated with a higher HCV viral load than
the therapy based in other dugs.
In recent years, the host’s genetic factors have played an important role in
predicting treatment response. Variations of the IL28B genotype are
considered to be the most important baseline factor for treatment response
among HIV co-infected patients and patients with the IL28B-CC genotype
(SNP rs12979860) achieve SVR significantly more frequently than those
bearing unfavorable genotypes (CT or TT). Several studies have suggested
that the effect of the IL28B genotype on HCV viral kinetics can be seen in
the first few days after start of treatment. There was however limited
information about the IL-28B effect once treatment has started and no data
about the effect on HIV/HCV co-infected patients. For this reason, we
designed a study to evaluate the effect of the IL28B genotype on HCV viral
kinetics in the first 4 weeks after start of treatment with Peg-IFN/RBV in
HIV/HCV co-infected patients. We found that bearing the IL28B-CC
genotype was related to greater HCV viral decline during the first weeks of
treatment with Peg-IFN/RBV among patients infected with HCV genotype
1 or 4, but not those infected with genotype 2 or 3. Because of the greater
viral decline, the rate of rapid virological response (RVR)—defined as an
undetectable HCV viral load at week 4—was higher among IL28B-CC
patients than among IL28B non-CC patients. We concluded therefore that
the higher SVR rate observed with IL28B in earlier studies might be due to
the higher RVR rate, the most predictive on-treatment factor of SVR.
Similarly, we hypothesized that the effect of the IL28B genotype on
treatment response could be influenced by various factors. It was necessary
to identify potential modulators of the IL28B effect influencing HCV
treatment response, which would be beneficial in clinical decision-making.
So we designed three studies:
First, the IL28B genotype is associated with plasma LDL cholesterol levels
and patients with IL28B-CC show significantly higher LDL cholesterol
levels than those harboring the non-CC genotype. There is no explanation
to date for this finding, although an interaction between IL28B and LDL
receptor (LDLR) genes could be hypothesized. So, we tested variations of
the LDLR genotype on HCV viral decline during the first weeks of
treatment among patients coinfected with HIV/HCV genotype 1, according
to their IL28B genotype. We found that patients carrying the LDLr-CC
genotype showed greater HCV viral decline than those with the LDLr nonCC genotype during the first 4 weeks of treatment. Similarly, we observed
that CC/CC patients had better rapid virological response (RVR) rates than
CC/non-CC patients (41.2 versus 13.3%; P<0.001), as well as greater HCV
viral decline than those with the CC/non-CC genotype during the first
weeks of treatment. We concluded therefore that LDLr genotype is a
pretreatment predictor of HCV kinetics in HIV/HCV co-infected patients
bearing genotype 1 who start therapy with Peg-IFN/RBV, and that it
modifies the effect of the IL28B genotype on HCV viral decline.
Second, the IL28B action mechanism has not been clearly explained. It has
however been suggested that IL28B variations have different endogenous
IFN activities (with IL28B-CC being lower than IL28B Non-CC). Thus,
patients with lower endogenous IFN activity would obtain a higher
response when exogenous IFN was added, leading to higher viral
clearance. As we reported for the first study in this phase, IL28B genotype
has no impact on HCV genotype 2 or 3 treatment response. Various clinical
trials have studied reduced doses in drug-based HCV therapy among
monoinfected HCV genotype 3 patients. Reducing the Peg-IFNa2a dose
from 180 mg/per week to 135 mg/per week was shown to give similar RVR
and SVR rates, so that a reduced dose of HCV treatment drugs was
appropriate for this population of patients. We hypothesized that a lower
Peg-IFN dose might modify the impact of IL28B on treatment response in
HIV/HCV genotype 3 co-infected patients, due to the mechanism of action
related to IL28B IFN, set out above. We therefore evaluated the impact of
IL28B on HCV viral decline during the first weeks of treatment in two
different HCV genotype 3 populations. The first group received the
standard dose of Peg-IFN/RBV, and the second, receiving lower doses of
both treatment drugs, were enrolled in an open-label clinical trial. We
found that the IL28B-CC genotype had greater HCV viral decline in the
standard dose group compared to the low drug dose group. However, the
greatest HCV viral decline was found among IL28B non-CC patients.
These findings suggest that HCV viral decline among patients with HCV
genotype 3 is not due to the IL28B genotype, but to the Peg-IFN/RBV
dose.
Thirdly, we evaluated the influence of IL28B genotype on HCV viral
decline between HCV genotype 1 subtypes (1a and 1b). In our study, the
IL28B-CC genotype had a positive effect on HCV viral clearance during
the first weeks of treatment with Peg-IFN-alpha-2a/RBV and on RVR rates
in HCV-1b genotype HIV co-infected patients, but not those with HCV-1a.
Due to this effect HCV-1b infected patients could have a higher treatment
response rate, as observed in elsewhere.
INTRODUCCIÓN:
1. Genoma y ciclo biológico del virus de la Hepatitis C (VHC).
1.1.
Características Genómicas del VHC
El virus de la hepatitis C (VHC) es un virus con envoltura, ARN
monocatenario positivo (de 9,6 Kb), perteneciente a la familia Flaviviridae,
genero Hepacivirus [1]. Han sido descritos siete genotipos (1, 2, 3, 4, 5, 6 y
7) virales, diferentes en más del 25% de los nucleótidos de su genoma, a su
vez divididos en subtipos (a, b, c, etc…) [2].
El genoma del VHC codifica 10 proteínas; 3 estructurales (core, E1 y
E2), cinco no estructurales (NS3, NS4A, NS4B, NS5A y NS5b), y 2
situadas entre las proteínas estructurales y no estructurales (p7 y NS2) más
similares a las proteínas no estructurales [3, 4].
1.2.
Ciclo biológico
El ciclo biológico del VHC puede dividirse en tres bloques: 1) anclaje y
fusión a la membrana del hepatocito, 2) translación y replicación viral, y 3)
ensamblaje y liberación de los virones.
1.2.1. Anclaje y fusión a la membrana del hepatocito
El VHC está íntimamente ligado al metabolismo lipídico, usando el
ciclo natural de las lipoproteinas para entrar en el hepatocito [5]. La forma
infectiva del VHC es la partícula lipo-viral (PLV), consistente en la
conjunción de la lipoproteína de muy baja densidad (VLDL) y el VHC [6].
La PLV se ancla a la superficie del hepatocito mediante su unión a
dos receptores, los glicosaminoglicanos (GAGs) y el receptor de la
lipoproteína de baja densidad (LDLr) (Figura 1A) [7, 8]. La fijación de la
PLV por parte de estos receptores se produce mediante la interacción de
dos componentes, uno viral (glicoproteínas de membrana E1 y E2) y otro
de la VLDL (apo-E). Tras esta unión, la PLV se une al scavenger-receptor
class B type I (SRB-1) mediante la región HVR1 de E2 [9]. La unión de
E2 al SRB-1 produce una modificación conformacional de las
glicoproteínas E1 y E2, aumentando la afinidad de E1 y E2 por otros
correceptores de la superficie del hepatocito, concretamente al cumulo de
diferenciación 81 (CD81). La unión de E2 a CD81 favorece la fusión y
endocitosis del virus (reacción pH dependiente) [10]. Recientemente, se
han descrito Claudina-1 y la Ocludina- 1, así como el receptor NiemannPick C1-like 1 cholesterol (NPC1L1)como nuevos factores de entrada al
hepatocito [11-13].
1.2.2 Translación y replicación viral
Dentro del hepatocito, la PLV es degrada en el citoplasma celular,
liberando el virus,produciéndose la decapsidación viral, liberando la cadena
de ARN+ al citoplasma celular [14]. Esta cadena se une por el extremo 5´
mediante la región de internación al ribosoma (IRES) al ribosoma del
retículo endoplasmático (RE) celular. El ribosoma codifica las 10 proteínas
del virus (tanto estructurales como no estructurales) produciendo una
cadena ARN- y una cadena de poliproteinas víricas [15]. En primer lugar,
se produce la escisión proteica mediante la acción proteasa de NS3,
conformándose estas 10 proteínas liberadas en la membrana del RE
formándose el complejo replicativo (Figura 1B) [16].
1.2.3. Ensamblaje y liberación de los virones
El ensamblaje y liberación, al igual que la entrada del virus, está
íntimamente relacionado con el metabolismo lipídico. El Core rodea los
cuerpos lipídicos (CL), organelas celulares encargadas de almacenar
triglicéridos y colesterol, produciendo su redistribución, haciendo que éstos
se sitúen alrededor del complejo replicativo viral [17]. NS5A desencadena
un mensaje de inicio del ensamblaje del virus. Una vez desencadenado el
ensamblaje, la membrana del RE se escinde hacia el citoplasma celular
[18]. Esta escisión lipídica contiene el material genético del virus (ARN+),
las proteínas víricas y componentes lipídicos conferidos por los CL [19].
De esta forma, está partícula viral entra en la VLDL donde madura. Una
vez formada la PLV salé del hepatocito infectado mediante el ciclo normal
de la lipoproteína VLDL, siendo la forma infectiva del VHC.
Figura 1: A) Anclaje y fusión en la membrana del hepatocito B) Formación del
complejo replicatico y conformación proteínas virales en membrana del retículo
endoplasmático (Rivero-Juarez A. Estructura Genómica y ciclo Biológico del
VHC. En Rivero A, Pineda JA Eds. Coinfección VIH y VHC; Málaga 2012: 1926).
2.
Aspectos epidemiológicos de la infección por el VHC
La infección por este virus es un problema de salud mundial que
afecta a más de 170 millones de personas, de las cuales se estima que
alrededor de 5 millones está coinfectada por el virus de la
inmunodeficiencia humana (VIH), esto supone el 20% del global de
personas infectadas por el VIH [20]. Esta proporción es mayor en regiones
en las que el consumo de drogas por vía parenteral ha constituido la
principal vía de transmisión del VIH. De esta forma en España
aproximadamente el 50% de los pacientes infectados por VIH se
encuentran coinfectados por el VHC [21]. Tras una infección aguda,
aproximadamente el 75% de los pacientes evolucionaran a infección
crónica mediante el desarrollo de una fibrosis hepática progresiva [22]. El
4-24% de los casos evolucionarán a cirrosis hepática y el 0,7-23% lo harán
hastacarcinoma hepatocelular [23]. La coinfección por VIH/VHC,
incrementa la probabilidad de cronificación de la hepatitis por VHC,
provoca unaprogresión mas acelerada de la fibrosis y, consecuentemente,
una mayor probabilidad de desarrollo de cirrosis hepática y enfermedad
hepática terminal [24-25]. La alta prevalencia de infección crónica por
VHC y la acelerada progresión de ésta enfermedad en pacientes infectados
por el VIH, han conseguido situar a la enfermedad hepática terminal como
una de las principales causa de muerte en estapoblación de pacientes [26,
27]. Por este motivo, el tratamiento de la infección crónica por VHC en
pacientes coinfectados por el VIH reviste una especial importancia.
3. Tratamiento frente a la infección crónica por el VHC en el paciente
coinfectado por el VIH
El tratamiento estándar frente al VHC ha cambiado de forma drástica
durante los últimos 15 años. En primer lugar, el tratamiento con interferón
(IFN) en monoterapia, posteriormente la incorporación de ribavirina
(RBV) a la terapia con IFN, la sustitución del INF estándar por interferónpegilado (IFN-Peg), y por último, recientemente, la incorporación de los
inhibidores de la proteasa NS3 (IPs), boceprevir (BOC) y Telaprevir
(TPV), al tratamiento de los pacientes con infección por genotipo 1 del
VHCen combinación con IFN-Peg/RBV [28]. Esta mejoría en el arsenal
terapéutico de la infección por el VHC, ha conseguido que el porcentaje de
pacientes que alcanzan Respuesta Viral Sostenida (RVS), gold estándar de
curación, pase de un dramático 5% a un esperanzador 70% (Tabla 1) [29 34]. Además, actualmente están en distintas fases de desarrollo más de 30
fármacos de acción directa (FAD) sobre el VHC, que mejorará aun más, el
pronóstico de los pacientes infectados por el VHC [35].
Tabla 1. Porcentaje de RVS en pacientes con genotipo 1 en los diferentes
ensayos en pacientes coinfectados por genotipo 1 del VHC y el VIH.
N
Pacientes con genotipo 1
(%)
RVS pacientes con
genotipo 1 (%)
APRICOT
ACTG 5071
RIBAVIC
Barcelona
Study 110
Boceprevir
868
133
412
95
60
64
60
77
48
55
100
100
29
14
17
38
70
60.7
3.1. Objetivos del tratamiento
El objetivo del tratamiento es conseguir la supresión sostenida de la
replicación viral del VHC y que ésta se mantenga de forma indefinida una
vez finalizado el tratamiento. Se considera que el tratamiento de un
paciente ha conseguido erradicar su infección por VHC cuando la carga
viral del VHC permanece indetectable24 semanas después de finalizar el
mismo. Esta situación ha sido definida comoRVS, y su consecución se
relaciona con curación de la enfermedad (Figura 2A).
Se han definido una serie de conceptos relacionados con la respuesta
viral obtenida durante el tratamiento que guardan una estrecha relación con
la probabilidad de alcanzar RVS, que son de gran utilidad en la toma de
decisiones respecto al mantenimiento o suspensión del tratamiento. A
continuación definiremos cada uno de estos conceptos que serán utilizados
a lo largo de la exposición [36]:
- Respuesta Viral rápida (RVR): definida como alcanzar una carga
viral del VHC indetectable tras 4 semanas (28 días) de tratamiento
(Figura 2B).
- Respuesta viral precoz parcial(RVPp): definida como la consecución
de un descenso de la carga viral del VHC de más de 2 log10UI/mL
tras 12 semanas de tratamiento (Figura 2C).
- Respuesta viral precoz completa (RVPc): definida como alcanzar
una carga viral indetectable del VHC en la semanas 12 de
tratamiento (Figura 2D).
- No Respuesta-Null Responder(NR): definida como conseguir un
descenso de la carga viral del VHC de 2 log UI/mL tras 12 semanas
de tratamiento (como ausencia de RVPp) (Figura 2E).
- Rebote viral-Viral Breakthrough(VB): definida como la reaparición
del ARN-VHC durante el tratamiento tras haber alcanzado su
indetectabilidad (Figura 2F).
- Respuesta
final
de
tratamiento
(RFT):
definida
como
la
indetectabilidad de la carga viral del VHC en el momento de
finalización del tratamiento (Figura 2G).
- Recidiva Viral-Viral Relapse (VR): definida como la reaparición del
ARN-VHC tras la retirada del tratamiento del VHC (Figura 2H).
Figura 2: Representación gráfica de la respuesta viral durante el tratamiento con
IFN-Peg/RBV (Rivero Juarez A). La línea roja discontinua marca el límite mínimo
de detectabilidad (1.15 log IU/mL).
3.2 Tratamiento con interferón pegilado más ribavirina:
La pauta estándar de tratamiento frente al VHC en pacientes
coinfectados por VIH es la combinación de IFN-Peg (α-2a a dosis de 180
µg/semana y α-2b a dosis de 1,5 µg/kg/semana) mas RBV ajustada a peso
(1.000 ó 1.200 mg/día respectivamente para pacientes con<75 kg ó ≥75 kg)
durante 48 semanas [36]. Las tasas de RVS alcanzadas con esta pauta en
los distintos ensayos clínicos depende del genotipo del VHC, oscilando
entre el 17-46% en pacientes con genotipos 1 ó 4, y entre el 43-71% en
pacientes con genotipo 2 ó 3 [29-34]. No se han encontrado diferencias en
las tasas de RVS entre los dos tipos de IFN-Peg (α-2a oα-2b) [37].
En cuanto a la dosis óptima que debe usarse en los pacientes VIH
infectados por genotipos 2 ó 3, la dosis recomendada es de 180 µg/semana,
independientemente del peso, para IFN-Peg α-2a y de 1,5 µg/kg/semana
para el α-2b [36]. No obstante, en pacientes monoinfectados por el VHC, se
ha demostrado que dosis menores de ambos fármacos (135 µg/semana de
IFN-Pegα-2a y 800mg/día de RBV) tienen similares tasas de RVS que las
dosis establecidas como estándar [38]. Sin embargo, esta recomendación
podría no ser extrapolada a la población coinfectada por el VIH. Respecto a
la dosis de RBV, en pacientes coinfectados la dosificación está menos
firmemente establecida. En la mayoría de los ensayos clínicos iniciales en
pacientes con infección por el VIH se utilizaron dosis de 800 mg/día de
RBV, independientemente del genotipo del VHC por temor a una mayor
incidencia de efectos adversos. En cambio, en pacientes coinfectados por
VIH no existen ensayos clínicos comparativos de la eficacia de diferentes
dosis de RBV en pacientes infectados por genotipo 2 ó 3, como pasa en
pacientes monoinfectados [39-41]. Del mismo modo, no existen evidencias
firmes que apoyen una dosificación estándar de RBV en pacientes VIH con
genotipo 2 ó 3 del VHC, aunque dada la peor respuesta que presentan estos
pacientes respecto a los pacientes monoinfectados la dosis de RBV debería
ajustarse al peso. El estudio del efecto de diferentes dosis de IFN-Peg/RBV
en la respuesta al tratamiento en pacientes coinfectados por el VIH y
genotipo 3 del VHC es uno de los objetivos de nuestro estudio.
Por su parte, en pacientes VIH coinfectados por genotipo 1 ó 4 del
VHC la dosis de IFN-Pegα-2a recomendada es de 180 µg/semana y de 1,5
µg/kg/semana para el α-2b [36]. En cambio, la dosis de RBV utilizada en
los ensayos clínicos de pacientes coinfectados no ha sido uniforme. En
algunos ha sido de 800 mg por temor a mayores tasas de efectos adversos
que en pacientes monoinfectados por el VHC y/o al desarrollo de
interacciones medicamentosas. Sin embargo, en los ensayos clínicos en los
que se ha usado RBV ajustada a peso, se han obtenido tasas de RVS más
altas; por ello, es la dosis recomendada [29-34].
La duración de la terapia podría individualizarse en función del
genotipo del VHC (1-4 ó 2-3) y de la cinética del VHC en respuesta al
tratamiento. Así por ejemplo,se ha sugerido que en pacientes con genotipos
4 que no alcanzan respuesta RVR ó RVPc, el tratamiento debería
prolongarse hasta 72 semanas, mientras que en pacientes con genotipo 3
que alcanzan RVR la terapia podría acortase hasta 24 semanas [36-42].
3.3 . Uso de FAD en pacientes coinfectados por VIH y Genotipo 1 del
VHC.
En los últimos años, se han desarrollado 2 FAD frente al VHC (TPV
y BOC) con alta actividad frente al genotipo 1 del VHC [43]. Estos nuevos
fármacos inhiben la acción como proteasa de la proteína NS3 del VHC. La
adición de estos nuevos fármacos a un régimen basado en IFN-Peg/RBV
consigue incrementar las tasas de RVS hastael 70% en pacientes sin
tratamiento previo. No hay ensayos que comparen la eficacia y seguridad
entre ambos fármacos, no obstante un reciente metanálisis indirecto llevado
a cabo en pacientes monoinfectados por VHC, no encontró diferencias en
su tasas de RVS [44-45].
En la actualidad no está aprobada la indicación TPV y BOCen
pacientes infectados por el VIH. En España, el acceso alos medicamentos
en condiciones diferentes a las autorizadas está reguladopor el Real
Decreto 1015/2009, de 19 de junio. Esta regulación, establece quela
Agencia Española de Medicamentos y Productos Sanitarios (AEMPS)
«podráelaborar recomendaciones de uso de medicamentos en condiciones
nocontempladas en la ficha técnica cuando el uso del medicamento en
estascondiciones suponga un impacto asistencial relevante». De este modo
laAEMPS ha elaborado unas recomendaciones que regula y permite el uso
deBOC y TPV en pacientes coinfectados por VIH/VHC [46]. Las
recomendaciones son:
Criterios dependientes del VHC
A.- Infección por VHC genotipo 1, independientemente de que
elpaciente haya recibido o no tratamiento previo para el VHC
B.- Fibrosis F3 y F4 confirmada por biopsia hepática o rigidez
hepáticamedida por Fibroscan >9.5 kPa. Independientemente del
grado defibrosis, se podrá considerar iniciar tratamiento con BOC o
TPV en pacientescon manifestaciones extrahepáticas graves de la
infección por VHC como porejemplo aquellas derivadas de la
crioglobulinemia mixta policlonal.
C.- Hepatopatía crónica compensada (Child-Pugh grado A)
D.- Concentración de hemoglobina >11 g/dl en mujeres y >12 g/dl
enhombres
Criterios dependientes del VIH
E.- Linfocitos CD4+ totales en sangre periférica >100 /ml o
porcentaje delinfocitos CD4+ >12%
F.- Carga viral plasmática de VIH <1000 copias/ml (pacientes en
tratamiento antirretroviral[TAR])
3.3.1. Uso de BOC
La estrategia de tratamiento con BOC consiste en un periodo de
lead-inde 4 semanas con IFN-Peg/RBV, tras la cual se administrará
conjuntamente BOC durante 44 semanas [47-48]. La posología de BOC es
de 800mg (4 comprimidos) cada 8 horas administrados con comida [49].
Esta pauta ha demostrado su superioridad en las tasas de RVS frente a IFN Peg/RBV en dos ensayos clínicos aleatorizados doble ciego, tanto en
pacientes que reciben un primer tratamiento como en previamente tratados
(respondedores parciales y recidivantes) monoinfectados por el VHC [4748]. Por otro lado, en población coinfectada los datos son escasos. Los
datos parciales de un ensayo clínico llevado a cabo en población naïve al
tratamiento con IFN-Peg/RBV, muestran un aumento significativo de las
tasas de RVS cuando se co-administra BOC con la terapia estándar [33].
3.3.2.Uso de TPV
La estrategia de tratamiento con Telaprevir consiste en la
administración de triple terapia con TPV+IFN-Peg/RBV durante 12
semanas, continuado de 36 semanas de tratamiento con IFN-Peg/RBV [5052]. La estrategia de administrar 4 semanas con IFN-Peg/RBV previas a la
administración de TPV, ha sido testada en pacientes monoinfectados por el
VHC previamente tratados [51, 53]. Los resultados derivados de esta
estrategia terapéutica mostraron no inferioridad en las tasas de RVS
respecto a la estrategia terapéutica convencional. Por lo que, TPV podría
ser usado siguiendo esta estrategia. La posología de TPV es de 750mg (2
comprimidos) cada 8 horas administrados con comida [49]. Esta estrategia,
comprobada en tres ensayos clínicos, ha demostrado superioridad frente a
la terapia estándar con IFN-Peg/RBV tanto en pacientes naïve como pretratados (nulos y parciales respondedores y pacientes recidivantes)
monoinfectados por el VHC [50-52]. Recientemente, se ha demostrado en
un ensayo clínico aleatorizado doble ciego realizado en población
monoinfectada por el VHC, que la administración de 1125 mg cada 12 de
TPV tiene unas tasas de RVS similares a la administración de la dosis de
750mg cada 8 horas [54]. Al igual que ocurre con Boceprevir, solo se
dispone de datosen población coinfectada por el VIH de un ensayo clínico
en pacientes naïve, en el que se compruéba la superioridad de TPV sobre la
terapia estándar en las tasas de RVS [34].
3.3.3. Limitaciones del tratamiento con Telaprevir y Boceprevir
El tratamiento del VHC con un régimen que incluya TPV o BOC adolece
de diversas limitaciones. En primer lugar, estos nuevos fármacos no han
mostrado actividad antiviral frente a los genotipos 2, 3 y 4, que provocan
cerca de la mitad de los casos de hepatitis crónica por VHC en nuestro
medio [42]. En segundo lugar, el uso de estos nuevos fármacos incrementa
la incidencia de efectos adversos respecto al régimen IFN-Peg/RBV, siendo
la anemia y el desarrollo de exantema los eventos más frecuentes [47, 48,
50-53]. En tercer lugar, la eficacia de estos fármacos en pacientes
infectados por VHC que no han respondido a un tratamiento previo con
IFN-Peg/RBV es inferior a la observada en pacientes sin tratamiento previo
[48-51]. Por último el uso de TPV o BOC supone un considerable aumento
del coste del tratamiento [55].
En pacientes coinfectados por el VIH el uso de estos FAD
presentaproblemas añadidos. La experiencia sobre la eficacia y seguridad
de estos fármacos en pacientes infectados por el VIH es muy limitada [33,
34]. Además existen interacciones farmacológicas entre estos nuevos
fármacos y los fármacos antirretrovirales que puede suponer una
importante limitación para su uso conjunto [56, 57].
3.3.4. Importancia de la identificación de subgrupos de pacientes con
alta probabilidad de alcanzar RVS con IFN-Peg/RBV.
En los ensayos clínicos de desarrollo de los IPs frente al VHC, las
tasas de RVS en las ramas controles (pacientes tratados con IFN-Peg/RBV)
fueron del 45% y el 29.5% respectivamente [33, 34]. Esto sugiere que una
significativa proporción de pacientes tratados con IFN-Peg/RBV puede
alcanzar RVS sin necesidad de usar FAD. Por ello, y dadas las limitaciones
del uso de FAD comentadas anteriormente, tendría un alto interés
estratégico identificar subgrupos de pacientes con hepatitis crónica por
VHC-genotipo 1 con alta probabilidad de alcanzar RVS con tratamiento
con IFN-Peg/RBV. Ello permitiría individualizarel tratamiento en los
pacientes infectados por genotipo 1 del VHCen función de la predicción de
tolerancia, del beneficio clínico esperado, de las futuras opciones
terapéuticas, y sobre de la predicción de la respuesta. Al mismo tiempo ello
permitiría optimizar el tratamiento de la población coinfectada por VIH y
genotipo 1 del VHC, al conseguir ahorrar recursos y efectos adversos
innecesarios en el subgrupo de pacientes que no se beneficiarían del uso de
FAD.
4. Predicción de la respuesta al tratamiento con IFN-Peg/RBV
En los últimos años se han descrito y estudiado múltiples factores,
determinados tanto en el momento basal como durante el tratamiento, con
un alto valor clínico y pronóstico de respuesta al tratamiento.
4.1.
Factores basales de respuesta al tratamiento del VHC
El grado de fibrosis/esteatosis hepática, la carga viral basal del VHC,
así como el propio genotipo del VHC y sus mutaciones tienen una relación
lineal inversa con la obtención de RVS [29-32, 58-62]. Por otro lado, en los
últimos 3 años, se han descrito factores genéticos, tanto del VHC como del
hospedador, con alto valor predictivo de respuesta al tratamiento del VHC
con IFN-Peg/RBV, que pueden en un futuro próximo jugar un papel
determinante en la toma de decisiones sobre el tipo y tiempo de tratamiento
frente al VHC. Entre ellos, cabe destacar las variaciones genotípicas
inmunológicas (HLA-C y Killer Immunoglobulin-like Receptors [KIRs] de
las células NK) [63, 64], implicadas en el ciclo del virus (LDLr) [65], así
como los relacionados con la sensibilidad del paciente al IFN (IL28B) [6668]. El estudio de estos factores es uno de los objetivos de nuestro estudio.
4.2 Cinética viral del VHC
El estudio de la cinética viral del VHC en respuesta al tratamiento
tiene una gran importancia en la predicción de la respuesta al mismo. Este
hecho ha sido claramente demostrado tanto con el tratamiento IFNPeg/RBV como con el tratamiento con los nuevos FAD.
La determinación de la cinética viral del VHC a las 4 semanas del
tratamiento con IFN-Peg/RBV ha demostrado gran utilidad en la predicción
de RVS. De este modo alcanzar negatividad de la carga viral del VHC a las
4 semanas de iniciado el tratamiento (RVR) se ha identificado como
elfactor con mayor valor predictivo positivo (VPP) para RVS [69-71]. En
este sentido, entre pacientes con genotipo 1 del VHC tiene especial
importancia la observación obtenida en los ensayos clínicos de desarrollo
de TPV y BOC. En estos el grupo de pacientes que alcanzó RVR en la
rama control (IFN-Peg/RBV) obtuvo unas tasas de RVS similares a
aquellos pacientes que recibieron triple terapia (FAD+IFN-Peg/RBV) [47,
50, 52]. Esta observación sugiere que aquellos pacientes que alcanzan RVR
no requerirían del uso de FAD para optimizar la probabilidad de respuesta
al tratamiento.
Por el contrario, no conseguir alcanzar un descenso de la carga viral
del VHC mayor de 1 log10 UI/mLa las 4 semanas de tratamiento conIFNPeg/RBV tiene un alto valor predictivo negativo de RVS [47, 50, 52, 72].
La determinación de la cinética viral del VHC a las 12 semanas del
tratamiento con IFN-Peg/RBV también ha demostrado gran utilidad en la
predicción de RVS. Así, no conseguir una reducción dela carga viral basal
del VHC enmas de 2 log10UI/mL a las 12 semanas de iniciado el
tratamiento con IFN-Peg/RBV (ausencia de RVP) se ha identificado como
el mejor factor predictivos negativo de RVS. De este modo la ausencia de
RVP se utiliza en la práctica clínica como regla de parada del tratamiento
del VHC con IFN-Peg/RBV [73].
Por último, la cinética viral a las 24 semanas de finalizado el
tratamiento (RVS) es el criterio utilizado para definir la curación de la
infección por VHC tras un curso de tratamiento [36].
El estudio de la cinética viral en respuesta al tratamiento con los
nuevos FAD resulta también de gran utilidad. En pacientes que reciben
tratamiento con BOC+IFN-Peg/RBV, no alcanzar una carga viral del VHC
inferior a 100 kUI/mL a las 12 semanas o no negativizarla a las 24, tiene un
alto valor predictivo negativo para RVS [74-76]. De tal modo que estos
criterio se utilizan en la práctica clínica como regla de parada del
tratamiento del VHC con BOC+IFN-Peg/RBV. Por otro lado, en pacientes
que reciben tratamiento con TPV+IFN-Peg/RBV, no alcanzar una carga
viral del VHC inferior a 1000 kUI/mL a las 4 semanas de tratamiento tiene
también un alto valor predictivo negativo para RVS y es utilizado como
regla de parada del tratamiento [75, 76].
No obstante, el valor pronóstico de la cinética viraldel VHC sobre la
respuesta al tratamiento con IFN-Peg/RBV adolece de varias limitaciones.
En primer lugar, la valoración de RVR permite clasificar tan soloa 1/3 de
los pacientes que alcanzarán RVS al tratamiento con IFN-Peg/RBV [71].
Por lo tanto, una gran parte de los pacientes que alcanzarán RVS no
podrían ser clasificados con esta regla. Por otro lado, para poder clasificar a
un paciente como no respondedor al tratamiento con IFN-Peg/RBV serían
necesarias 12 semanas de tratamiento (ausencia de RVPp), exponiendo al
paciente a efectos adversos. Por último, para establecer curación (RVS) es
necesario esperar 24 semanas tras la retirada del tratamiento [36]. Por ello,
la búsqueda de puntosmás precoces en la cinética viral y/o la
implementación de nuevas criterios con alto valor pronóstico de respuesta
que permitieran identificar un
mayor numero de pacientes, tanto
respondedores como no respondedores al tratamiento con IFN-Peg/RBV,
tendría una alta relevancia clínica. Ello permitiría la implementación de
alternativas terapéuticas precoces. El estudio de nuevos criterios de la
cinética viral con alto valor pronóstico sobre RVS es uno de los objetivos
de nuestro estudio.
Referencias:
[1] Ashfaq AU, Javed T, Rehman S, Nawaz Z, Riazuddin S. An overview
of HCV molecular biology, replication and immune responses. Virology
Journal 2011; 8:161.
[2] Lau, JYN, Mizokami M, Kolberg JA et al. Application of six hepatitis
C virus genotyping systems to sera from chronic hepatitis C patients in the
United States. J Infect Dis 1995; 171: 181–189.
[3] Lohmann V, Koch JO, Bartenschlager R. Processing pathways of the
hepatitis C virus proteins. J Hepatol 1996; 24: 11−19.
[4] Penin, F, Dubuisson J, Rey FA, Moradpour D, Pawlotsky JM.
Structural biology of hepatitis C virus. Hepatology 2004; 39: 5−19.
[5] Popescu CI, Dubuisson J. Role of lipid metabolism in hepatitis C virus
assembly and entry. Biol Cell 2009; 102: 63-74.
[6] Andre P, Komurian-Pradel F, Deforges S et al. Characterization of lowand very-low-density hepatitis C virus RNA-containing particles. J Virol
2002; 76: 6919-28.
[7] Agnello V, Abel G, Elfahal M, Knight GB, Zhang QX. Hepatitis C
virus and other flaviviridae viruses enter cells via low density lipoprotein
receptor. Proc Natl Acad Sci U S A 1999; 96: 12766-12771.
[8] Barth H, Schafer C, Adah MI et al. Cellular binding of hepatitis C virus
envelope glycoprotein E2 requires cell surface heparan sulfate. J Biol Chem
2003; 278: 41003-41012.
[9] Carselli E, Ansuini H, Cerino R et al. The human scavenger receptor
class B type I is a novel candidate receptor for the hepatitis C virus. EMBO
J 2002; 21: 5017-5025.
[10] Pileri P, Uematsu Y, Campagnoli S et al. Binding of hepatitis C virus
to CD81. Science 1998; 282: 938-941.
[11] Evans MJ, Von-Hahn T, Tscherne DM et al. Claudin-1 is a hepatitis C
virus co-receptor required for a late step in entry. Nature 2007; 446: 801-5.
[12] Ploss A, Evans MJ, Gaysinskaya VA et al. Human occludin is a
hepatitis C virus entry factor required for infection of mouse cells. Nature
2009; 457: 882-6.
[13] Sainz B Jr, Barretto N, Martin DN et al. Identification of the
Niemann-Pick C1–like 1 cholesterol absorption receptor as a new hepatitis
C virus entry factor. Nat Med 2012; 18: 281-5.
[14] Machlin ES, Sarnow P, Sagan SM. Masking the 5’ terminal
nucleotides of the hepatitis C virus genome by an unconventional
microRNA-target RNA complex. Proc Natl Acad Sci U S A 2011; 108:
3193-8.
[15] El-Hage N, Luo G. Replication of hepatitis C virus RNA occurs in a
membrane-bound replication complex containing nonstructural viral
proteins and RNA. J Gen Virol 2003; 84: 2761-2769.
[16] Gosert R, Egger D, Lohmann V et al. Identification of the hepatitis C
virus RNA replication complex in Huh-7 cells harboring subgenomic
replicons. J Virol 2003; 77: 5487-5492.
[17] Popescu CI, Rouille Y, Dubuisson J. Hepatitis C virus assembly
imaging. Viruses 2011; 3: 2238-54.
[18] Barba G, Harper F, Harada T et al. Hepatitis C virus core protein
shows a cytoplasmic localization and associates to cellular lipid storage
droplets. Proc Natl Acad Sci U S A 1997; 94: 1200-5.
[19] Miyanari Y, Atsuzawa K, Usuda N et al. The lipid droplet is an
important organelle for hepatitis C virus production. Nat Cell Biol 2007; 9:
1089-97.
[20] Taylor LE, Swan T, Mayer KH. HIV coinfection with hepatitis C
virus: evolving epidemiology and treatment paradigms. Clin Infect Dis
2012; 55 (Suppl 1): S33-42
[21] Pérez-Cachafeiro S, del Amo J, Iribarren JA et al. Decrease in serial
prevalence of coinfection with hepatitis C among HIV-infected patients in
Spain, 1997-2006. Clin Infect Dis 2009; 48: 1467-1470
[22] Maasoumy B, Wedemeyer H. Natural history of acute and chronic
hepatitis C. Best Pract Res Clin Gastroenterol 2012; 26: 401-12.
[23] Merchante N, Merino E, López-Aldeguer J et al. Increasing incidence
of hepatocellular carcinoma in HIV-infected patients in Spain. Clin Infect
Dis 2013; 56: 143-50.
[24] Pineda JA, Romero-Gómez M, Díaz-García F et al. HIV coinfection
shortens the survival of patients with hepatitis C virus-related
decompensated cirrhosis. Hepatology 2005; 41: 779-89.
[25] Pineda JA, Garcia-Garcia JA, Aguilar-Guisado M et al. Clinical
progression of hepatitis C virus-related chronic liver disease in human
immunodeficiency
virus-infected
patients
undergoing
higly
active
antiretroviral therapy. Hepatology 2007; 46: 622-30.
[26] Hernando V, Sobrino-Vegas P, Burriel MC et al. Differences in the
causes of death of HIV-positive subjects in a cohort study by data sources
and coding algorithms. AIDS 2012; 26: 1829-1834.
[27] Branch AD, Van Natta ML, Vachon ML et al; for the Studies of the
Ocular Complications of AIDS Research group. Mortality in HCV-infected
Patients with a Diagnosis of AIDS in the Era of Combination Antiretroviral Therapy. Clin Infect Dis 2012; 55: 137-144
[28] Hofmann MW and Zeuzem S. A new standard of care for the
treatment of chronic HCV infection. Nat Rev Gastroenterol Hepatol 2011;
8: 257-264.
[29] Carrat F, Bani-Sadr F, Pol S et al. Pegylated interferon alfa-2b vs
standard interferon alfa-2b, plus ribavirin, for chronic hepatitis C in HIVinfected patients: a randomized controlled trial. JAMA 2004; 292: 2839-48
[30] Torriani FJ, Rodriguez-Torres M, Rockstroh JK et al. Peginterferon
Alfa-2a plus ribavirin for chronic hepatitis C virus infection in HIVinfected patients. N Engl J Med 2004; 351: 438-50
[31] Chung RT, Andersen J, Volberding P et al. Peginterferon Alfa-2a plus
ribavirin versus interferon alfa-2a plus ribavirin for chronic hepatitis C in
HIV-coinfected persons. N Engl J Med 2004; 351: 451-9
[32] Laguno M, Murillas J, Blanco JL et al. Peginterferon alfa-2b plus
ribavirin compared with interferon alfa-2b plus ribavirin for treatment of
HIV/HCV co-infected patients. AIDS 2004; 18: 27-36
[33] Sulkowski MS, Pol S, Cooper C et al. Boceprevir + Pegylated
Interferon + Ribavirin for the Treatment of HCV/HIV-co-infected Patients:
End of Treatment (Week-48) Interim Results. 19th Conference on
Retroviruses and Opportunistic Infections (CROI 2012) Seattle, WA.
March 5-8, 2012. Abstract 47
[34] Sulkowski MS, Sherman KE, Soriano V et al. Telaprevir in
combination with peginterferon alfa-2a/ribavirin in HIV/HCV co-infected
patients: SVR24 final study results. 63rd AASLD. 2012, Boston. Abstract
54
[35] Stedman CAM. Current prospects for interferon-free treatment of
hepatitis C in 2012. J Gastroenterol Hepatol 2013; 28: 38-45.
[36] Ghany MG, Strader DB, Thomas DL, Seeff LB; American Association
for the Study of Liver Diseases. Diagnosis, management, and treatment of
hepatitis C: an update. Hepatology 2009; 49: 1335-74
[37] McHutchison JG, Lawitz EJ, Shiffman ML et al. Peginterferon Alfa2b or Alfa-2a with Ribavirin for Treatment of Hepatitis C Infection. N Engl
J Med 2009; 361: 580-93.
[38] Lopez-Cortes LF, Valera-Bestard B, Gutierrez-Valencia A et al. Role
of pegylated interferon-alpha-2a and ribavirin concentrations in sustained
viral response in HCV/HIV-coinfected patients. Clin Pharmacol Ther
2008; 84: 573-80.
[39] Pockros PJ, Carithers R, Desmond P et al; PEGASYS International
Study Group. Efficacy and safety of two-dose regimens of peginterferon
alpha-2a compared with interferon alpha-2a in chronic hepatitis C: a
multicenter randomized controlled trial. Am J Gastroenterol 2004; 99:
971–81
[40] Jacobson IM, Brown RS Jr, Freilich B et al: WIN-R Study Group.
Peginterferon alfa-2b and weight-based or flat-dose ribavirin in chronic
hepatitis C patients: a randomized trial. Hepatology 2007; 46: 971–81
[41] Ferenci P, Brunner H, Laferl H et al: Austrian Hepatitis Study Group.
A randomized, prospective trial of ribavirin 400 mg/day versus 800 mg/day
in combination with peginterferon alfa-2a in hepatitis C virus genotype 2
and 3. Hepatology 2008; 47: 1816–23.
[42] European Association for the Study of the Liver. EASL Clinical
Practice Guidelines: management of hepatitis C virus infection. J Hepatol
2011; 55: 245- 64.
[43] Liu S, Cipriano LE, Holodniy M, Owens DK, Goldhaber-Fiebert JD.
New Protease Inhibitor for the treatment of chronic hepatitis C. Ann Intern
Med 2012; 156: 279-290
[44] Kieran J, Schmitz S, O'Leary A et al. The relative efficacy of
boceprevir and telaprevir in the treatment of hepatitis C virus genotype 1.
Clin Infect Dis 2013; 56: 228-35.
[45] Cooper CL Druyts E, Thorlund K et al. Boceprevir and telaprevir for
the treatment of chronic hepatitis C genotype 1 infection: an indirect
comparison meta-analysis. Ther Clin Risk Manag 2012; 8: 105–130
[46] AEMPS. Criterios y recomendaciones generales para el tratamiento
con boceprevir y telaprevir de la hepatitis crónica C (VHC) en pacientes
co-infectados
por
el
VIH,
trasplantados
de
hígado
y
niños.
http://www.aemps.gob.es/medicamentosUsoHumano/informesPublicos/doc
s/criterios-VHC-off- label.pdf
[47] Poordad F, McCone J, Bacon BR et al. Boceprevir for Untreated
Chronic HCV Genotype 1 Infection. N Engl J Med 2011; 364: 1195-206.
[48] Bacon BR, Gordon SC, Lawitz E et al. Boceprevir for Previously
Treated Chronic HCV Genotype 1 Infection. N Engl J Med 2011; 364:
1207-17.
[49] Thomas DL, Bartlett JG, Peters MG, Sherman KE, Sulkowski MS,
Pham PA. Provisional guidance on the use of hepatitis C virus protease
inhibitors for treatment of hepatitis C in HIV-infected persons. Clin Infect
Dis 2012; 54: 979-83.
[50] Jacobson IM, McHutchison JG, Dusheiko G et al. Telaprevir for
previously untreated chronic hepatitis C virus infection. N Engl J Med
2011; 364: 2405-2416.
[51] Zeuzem S, Andreone P, Pol S et al. Telaprevir for retreatment of HCV
infection. N Engl J Med 2011; 364: 2417-28
[52] Sherman KE, Flamm SL, Afdhal NH et al. Response-guided telaprevir
combination treatment for hepatitis C virus infection. N Engl J Med 2011;
365: 1551-24
[53] Foster GR, Zeuzem S, Andreone P et al. Sustained virological
response rates with telaprevir by response after 4 weeks of lead-in therapy
in patients with prior treatment failure. J Hepatol 2013; 58: 488-494
[54] Buti M, Agarwal K, Horsmans YJ et al. OPTIMIZE trial: Noninferiority of twice-dayle telaprevir versus administration every 8 hours in
treatment-naïve, genotype 1 HCV infected patients. 63rd Annual Meeting
of the American Association for the Study of the Liver. November 9-13
2012, Boston, USA. Abstract LB-8
[55] Gellad ZF, Reed SD, Muir AJ. Economic evaluation of direct-acting
antiviral therapy in chronic hepatitis C. Antiviral Ther 2012; 17: 1189-99.
[56] Kiser JJ, Burton JR, Anderson PL, Everson GT. Review and
managment of drug interactions with boceprevir and telaprevir. Hepatology
2012; 55: 1620-8.
[57] Seden K, Back D. Directly acting antivirals for hepatitis C and
antiretrovirals: potential for drug-drug interactions. Curr Opin HIV AIDS
2011; 6: 514–26
[58] Shirakawa H, Matsumoto A, Joshita S et al. Pretreatment prediction of
virological response to peginterferon plus ribavirin therapy in chronic
hepatitis C patients using viral and host factors. Hepatology 2008; 48:
1753–1760.
[59] Cheng WS, Roberts SK, McCaughan G et al. Low virological
response and high relapse rates in hepatitis C genotype 1 patients with
advanced fibrosis despite adequate therapeutic dosing. J Hepatol 2010; 53:
616-623
[60] Akuta N, Suzuki F, Kawamura Y et al. Predictive factors of early and
sustained responses to peginterferon plus ribavirin combination therapy in
Japanese patients infected with hepatitis C virus genotype 1b: amino acid
substitutions in the core region and low- density lipoprotein cholesterol
levels. J Hepatol 2007; 46: 403–410
[61] Donlin MJ, Cannon NA, Yao E et al. Pretreatment sequence diversity
differences in the full-length hepatitis C virus open reading frame correlate
with early response to therapy. J Virol 2007; 81: 8211-24
[62] Enomoto N, Sakuma I, Asahina Y et al: Mutations in the nonstructural
protein 5A gene and response to interferon in patients with
hepatitis C virus 1b infection. N Engl J Med 1996; 334: 77–81
chronic
[63] Suppiah V, Gaudieri S, Armstrong NJ et al. IL28B, HLA-C,
and KIR variants additively predict response to therapy in chronic hepatitis
C virus infection in a European Cohort: a cross-sectional study. PLoS Med
2011; 8: e1001092.
[64] Khakoo SI, Thio CL, Martin MP et al. HLA and NK cell inhibitory
receptor genes in resolving hepatitis C virus infection. Science 2004; 305:
872–874
[65] Pineda JA, Caruz A, Di Lello FA et al. Low-density lipoprotein
receptor genotyping enhances the predictive value of IL28B genotype for
the response to pegylated interferon plus ribavirin in HIV/hepatitis C viruscoinfected patients with genotype 1 or 4. AIDS 2011; 25: 1415-1420
[66] Ge D, Fellay J, Thompson AJ et al. Genetic variation in IL28B
predicts hepatitis C treatment-induced viral clearance. Nature 2009; 461:
399–401
[67] Pineda JA, Caruz A, Rivero R et al. Prediction of response to
pegylated interferon plus ribavirin by IL28B gene variation in patients
coinfected with HIV and hepatitis C virus. Clin Infect Dis 2010; 51: 788795
[68] Naggie S, Osinusi A, Katsounas A et al. Dysregulation of innate
immunity in hepatitis C virus genotype 1 IL28B-unfavorable genotype
patients: impaired viral kinetics and therapeutic response. Hepatology
2012; 56: 444-54
[69] Fried MW, Hadziyannis SJ, Shiffman ML, Messinger D, Zeuzem S.
Rapid virological response is the most important predictor of sustained
virological response across genotypes in patients with chronic hepatitis C
virus infection. J Hepatol 2011; 55: 69-75
[70] Nuñez M, Mariño A, Miralles C et al. Baseline Serum Hepatitis C
Virus (HCV) RNA Level and Response at Week 4 Are the Best Predictors
of Relapse After Treatment With Pegylated Interferon Plus Ribavirin in
HIV/HCV-Coinfected Patients. J Acquir Immune Defic Syndr 2008; 45:
439-44
[71] Mira JA, Valera-Bestard B, Arizcorreta-Yarza A et al. Rapid
virological response at week 4 predicts response to pegylated interferon
plus ribavirin among HIV/HCV-coinfected patients. Antivir Ther 2007; 12:
523- 529
[72] Suzuki H, Kakizaki S, Horiguchi N et al. Clinical characteristics of
null responders to Peg-IFNα2b/ribavirin therapy for chronic hepatitis C.
WJH 2010; 2: 401–405
[73] Buenestado-Garcia J, Rubio-Rivas M, Reñé-Espinet JM et al. Early
virologic response value as predictive factor os sustained virologic
response to treatment with interferon alpha-2b plus ribavirin in chronic
hepatitis C patients with or without HIV coinfection. Med Clin 2006; 127:
561-6
[74] Poordad F, Bronowicki JP, Gordon SC et al. Factors That Predict
Response of Patients With Hepatitis C Virus Infection to Boceprevir.
Gastroenterology 2012; 143: 608-18
[75] Harrington PR, Zeng W, Naeger LK. Clinical relevance of detectable
but not quantifiable hepatitis C virus RNA during boceprevir or telaprevir
treatment. Hepatology 2012; 55: 1048–57.
[76] Jacobson IM, Marcellin P, Zeuzem S et al. Refinement of stopping
rules during treatment of hepatitis c-genotype 1 infection with boceprevir
combined with peginterferon/ ribavirin. Hepatology 2012; 56: 567–75.
OBJETIVOS:
1. Evaluar el valor predictivo positivo sobre RVS de la determinación
de la carga viral del VHC en la semana 12 tras finalización del
tratamiento.
2. Evaluar la influencia del genotipo de IL28B (rs129679860) en la
respuesta al tratamiento del VHC con IFN-Peg/RBV mediante el
estudio de lacinética viral del VHCdurante las primeras semanas de
inicio del tratamiento.
3. Evaluar la influencia del genotipo de LDLr (rs14158) en la respuesta
al tratamiento del VHC con IFN-Peg/RBV mediante el estudio de la
cinética viral del VHC durante las primeras semanas de inicio del
tratamiento.
4. Evaluar el efecto de distintas dosis de IFN-Peg/RBV en la respuesta
al tratamiento mediante el estudio de la cinética viral del VHC
durante las primeras semanas de inicio del tratamiento en pacientes
coinfectados por el VIH y genotipo 3 del VHC.
5. Identificar factores basales asociados a recidivas al tratamiento del
VHC con IFN-Peg/RBV.
6. Evaluar la influencia del uso de distintos fármacos antirretrovirales
en la carga viral basal del VHC.
Journal of Antimicrobial Chemotherapy Advance Access published March 17, 2011
J Antimicrob Chemother
doi:10.1093/jac/dkr091
Twelve week post-treatment follow-up predicts sustained
virological response to pegylated interferon and ribavirin
therapy in HIV/hepatitis C virus co-infected patients
Antonio Rivero-Juárez1, José A. Mira2, Inés Pérez-Camacho3, Juan Macı́as2, Angela Camacho1, Karin Neukam2,
Julián Torre-Cisneros1, Nicolás Merchante2, Juan A. Pineda2 and Antonio Rivero1* on behalf of the Viral Hepatitis
Study Group, part of the Sociedad Andaluza de Enfermedades Infecciosas (SAEI) (Andalusian Society for
Infectious Diseases)
1
2
*Corresponding author. Unidad de Enfermedades Infecciosas, Instituto Maimónides de Investigación Biomédica (IMIBIC), Hospital Universitario Reina
Sofı́a, Córdoba, Spain. Tel: +34-957012421/0034; Fax: +34-957011885; E-mail: [email protected]
Received 3 November 2010; returned 17 January 2011; revised 31 January 2011; accepted 16 February 2011
Objectives: The aim of this study was to evaluate whether the assessment of hepatitis C virus (HCV) RNA serum
at 12 weeks after the end of treatment (W12) was as informative as after 24 weeks (W24) for determining sustained virological response (SVR) in HIV/HCV co-infected patients who received a combination of pegylated
interferon (PEG-INF) plus ribavirin (PEG-INF/RBV) and had a virological response at the end of treatment.
Methods: Treatment-naive HIV/HCV patients were included in this prospective study if they had completed a full
course of therapy with PEG-INF/RBV, had an undetectable serum HCV RNA at the end of treatment and complied with the W12 and W24 schedule for determining HCV RNA. HCV RNA levels were measured using a quantitative PCR assay (detection limit ¼ 15 IU/mL). Positive predictive value (PPV) was defined as the probability of
an undetectable serum HCV RNA at W12 and W24 after the end of treatment.
Results: Of 186 patients treated during the study period, 104 (55.9%) were included in the study. At W24, 83
(79.8%) patients had an SVR and 21 (20.2%) had a virological relapse. At W12, HCV RNA was undetectable in 83
(79.8%) patients and all of these had SVR. Undetectable HCV RNA at W12 had a 100% PPV [95% confidence
interval (CI) 96.5% –100%] for SVR.
Conclusions: Our results show that undetectable HCV RNA at W12 post-treatment has a high PPV for SVR.
Testing for HCV RNA at this moment may therefore be considered an appropriate point in time for identifying
SVR and relapse in HIV/HCV co-infected patients receiving treatment with PEG-INF/RBV.
Keywords: hepatitis C virus, human immunodeficiency virus, relapse, sustained viral response
Introduction
Pegylated interferon (PEG-INF) plus ribavirin (PEG-INF/RBV) is the
standard treatment for chronic hepatitis C virus (HCV) infection.
Achieving a sustained virological response (SVR), associated
with durable eradication of infection, is the therapeutic goal for
patients with chronic HCV.1,2 The SVR for patients with chronic
HCV infection is defined as an undetectable serum HCV RNA
24 weeks after discontinuation of treatment (W24). This definition is based on the results of many previous reports showing
that the odds of HCV reappearing once SVR has been achieved
are very low.1 – 3 For this reason, testing for HCV RNA at W24 is
the current gold standard for measuring the success of antiviral
therapy in chronic HCV infection.4
However, in HCV mono-infected patients, relapses generally
occur soon after a successful therapy has been discontinued,
and thus several studies have shown that testing HCV monoinfected patients for serum HCV RNA 12 weeks following completion of standard PEG-INF/RBV therapy (W12) could predict
SVR.5,6
In Western countries, a significant proportion of patients
with chronic HCV infection are also co-infected with HIV.
# The Author 2011. Published by Oxford University Press on behalf of the British Society for Antimicrobial Chemotherapy. All rights reserved.
For Permissions, please e-mail: [email protected]
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Infectious Diseases Unit, Maimonides Institute for Biomedical Research (IMIBIC), University Hospital Reina Sofia, Cordoba, Spain;
Clinical Unit for Infectious Diseases, University Hospital de Valme, Seville, Spain; 3Internal Medicine Service, Hospital de Poniente,
Almeria, Spain
Rivero-Juárez et al.
HIV-associated immune disorders could in theory impair definitive clearance of HCV infection after HCV therapy and alter the
timing of an HCV relapse. There is limited information about
testing HCV RNA at W12 post-treatment to evaluate SVR in
HIV/HCV co-infected patients and studies are needed to clarify
this issue.7 The objective of this study was to evaluate if measuring serum HCV RNA at W12 is as informative as at W24 to predict
SVR in HIV/HCV co-infected patients with a virological end of
treatment response (ETR).
Patients and methods
Patients
This study was designed and performed according to the Helsinki
declaration and was approved by the Ethics Committees of both participating hospitals.
Results
A total of 186 HIV patients infected with chronic HCV were
treated with PEG-INF/RBV during the study period. The baseline
characteristics of all patients are shown in Table 1. Of the
initial population treated, 82 patients (44.1%) experienced
early virological failure or viral breakthrough during treatment,
were discontinued prematurely because of adverse effects or
were lost to follow-up before they achieved ETR. Overall, only
104 (55.9%) of the initial population completed a full course of
therapy and achieved ETR. All of these complied with the W12
and W24 post-treatment follow-up schedules. At W24, 83
(79.8%) patients had an SVR and 21 (20.2%) had a VR.
At W12, serum HCV RNA was undetectable in 83 (79.8%)
patients and all achieved SVR (Table 2). No relapse was observed
after W12. Undetectable HCV RNA at W12 had a 100% (95% CI
96.5% –100%) PPV for SVR.
Discussion
Treatment regimens
All individuals were treated with either PEG-INF a2a or PEG-INF a2b at
doses of 180 mg or 1.5 mg/kg/week, respectively, in combination with a
weight-adjusted dose of oral ribavirin (1000 mg/day for ,75 kg and
1200 mg/day for ≥75 kg). Following international guidelines,7 patients
with HCV genotypes 1 or 4 received either 48 or 72 weeks of treatment,
and patients with HCV genotype 3 received 24 or 48 weeks of treatment,
in accordance with the decision of the physician responsible for the
patient. At weeks 12 and 24, PEG-INF/RBV was discontinued in nonresponding individuals.
Definitions of virological responses
ETR and SVR were defined as an undetectable serum HCV RNA at the end
of therapy and at 24 weeks following the end of treatment, respectively.
A non-response was defined as a detectable serum HCV RNA at the end
of treatment. Virological breakthrough was defined as detectable plasma
HCV RNA after week 24 of therapy in patients with a previously undetectable HCV viral load. Virological relapse (VR) was defined as an undetectable serum HCV RNA at the end of treatment and a detectable serum
HCV RNA at the 24 week post-treatment follow-up.
This study, carried out on a cohort of HIV/HCV co-infected
patients treated with PEG-INF/RBV, suggests that testing HCV
Table 1. Baseline characteristics of patients
Characteristics
N
Male, n (%)
Age in years, mean (SD)
BVL .600000, n (%)
Genotypes 1 and 4, n (%)
CD4 ,250 cells/mm3, n (%)
Category C (CDC), n (%)
HAART, n (%)
Liver fibrosis F3/F4, n (%)
Cirrhosis, n (%)
Interferon a2a, n (%)
ETR
SVR
VR
104
84 (80.8)
40.9 (5.5)
56 (53.8)
49 (47.1)
12 (11.5)
34 (32.7)
85 (81.7)
41 (39.4)
23 (22.1)
75 (72.1)
83
67 (80.7)
40.9 (5.6)
41 (49.4)
35 (42.2)
9 (10.8)
30 (36.1)
68 (81.9)
26 (31.3)
18 (21.7)
59 (71.1)
21
17 (81.0)
41.6 (5.1)
15 (71.4)
14 (66.7)
3 (14.3)
4 (19.0)
17 (81.0)
15 (71.4)
5 (23.8)
16 (76.1)
BVL, baseline viral load; HAART, highly active antiretroviral treatment.
Virological evaluation
Plasma HCV RNA load measurements were performed using a quantitative PCR assay (Cobas TaqMan, Roche Diagnostic Systems Inc., Pleasanton,
CA, USA), with a detection limit of 15 IU/mL.
Statistical analysis
The descriptive statistics of the patients are reported. Continuous variables are summarized as means+SD and categorical variables as frequencies and percentages. The positive predictive value (PPV) was
defined as the probability that an undetectable serum HCV RNA would
occur at W12 and W24 following the end of treatment.
2 of 3
Table 2. Serum HCV RNA outcome during the 24 week post-treatment
follow-up
Serum HCV RNA
(follow-up)
End of
treatment
W12
W24
Patients with
HCV RNA (2)
Patients
with SVR
PPV (95% CI)
104
83
79.8% (71.3%–86.7%)
83
83
83
83
100% (96.5%–100%)
100% (96.5%–100%)
One hundred and eighty-six HIV-infected patients with chronic hepatitis
receiving a combination therapy of PEG-INF/RBV were followed prospectively at two reference hospitals in Spain between January 2005 and
June 2008. All patients were treatment naive. The criteria used to determine HCV therapy were in accordance with international guidelines.7
Patients were included in this prospective study if they had completed
a full course of therapy with ETR and complied with the 12 week and
24 week post-treatment follow-up schedule for determining serum HCV
RNA. Patients who were positive for the hepatitis B surface antigen
(HBsAg) were excluded.
Ethical aspects
Twelve week follow-up to define sustained virological response
15 IU/mL may be considered an appropriate timepoint for assessing virological response and identification of SVR and relapse in
HIV/HCV co-infected patients treated with PEG-INF/RBV for
chronic HCV. Studies are needed to confirm these results.
Funding
This work was supported by the Ministerio de Sanidad y Consumo, Instituto de Salud Carlos III, Red de SIDA (AIDS Network) (all Spain)
(ISCIII-RETIC RD06/006).
Transparency declarations
A. R. has received consulting fees from Bristol-Myers Squibb, Abbott,
Gilead, Roche and Boehringer Ingelheim. J. A. P. has received consulting
fees from GlaxoSmithKline, Bristol-Myers Squibb, Abbott, Gilead, Merck
Sharp & Dohme, Janssen-Cilag and Boehringer Ingelheim. They have
received research support from GlaxoSmithKline, Roche, Bristol-Myers
Squibb, Schering-Plough, Abbott and Boehringer Ingelheim and have
received lecture fees from GlaxoSmithKline, Roche, Abbott, Bristol-Myers
Squibb, Boehringer Ingelheim and Schering-Plough. The remaining
authors have no conflicts of interest to declare.
References
1 Maylin S, Martinot-Peignoux M, Moucari M et al. Eradication of hepatitis
C virus in patients successfully treated for chronic hepatitis C.
Gastroenterology 2008; 135: 821–9.
2 George SL, Bacon BR, Brunt EM et al. Clinical, virologic, histologic and
biochemical outcomes after successful HCV therapy: a 5-year follow-up
of 150 patients. Hepatology 2009; 49: 729– 38.
3 Veldt B, Saracco G, Boyer N et al. Long term clinical outcome of chronic
hepatitis C patients with sustained virological response to interferon
monotherapy. Gut 2004; 53: 1504–8.
4 Ghany MG, Strader DB, Thomas DL et al. Diagnosis, management and
treatment of hepatitis C: an update. AASLD Practice Guidelines.
Hepatology 2009; 49: 1335–74.
5 Zeuzem S, Heathcote EJ, Shiffman ML et al. Twelve weeks of follow-up
is sufficient for the determination of sustained virologic response in
patients treated with interferon alpha for chronic hepatitis C. J Hepatol
2003; 39: 106–11.
6 Martinot-Peignoux M, Stern C, Maylin S et al. Twelve weeks
posttreatment follow-up is as relevant as 24 weeks to determine the
sustained virologic response in patients with hepatitis C virus receiving
pegylated interferon and ribavirin. Hepatology 2010; 51: 1122–6.
7 Medrano J, Barreiro P, Resino S et al. Rate and timing of hepatitis C virus
relapse after a successful course of pegylated interferon plus ribavirin in
HIV-infected and HIV-uninfected patients. Clin Infect Dis 2009; 49:
1397– 401.
8 Soriano V, Puoti M, Sulkowski M et al. Care of patients coinfected with
HIV and hepatitis C virus: 2007 updated recommendations from the
HCV-HIV International Panel. AIDS 2007; 21: 1073– 89.
9 Aghemo A, Rumi MG, De Nicolla S et al. Twelve-week posttreatment
follow-up predicts a sustained virological response to pegylated
interferon and ribavirin therapy. Hepatology 2010; 52: 1170–1.
10 Gerotto M, Dal Pero F, Bortoletto G et al. Hepatitis C minimal residual
viremia (MRV) detected by TMA at the end of Peg-IFN plus ribavirin
therapy predicts post-treatment relapse. J Hepatol 2006; 44: 83–7.
3 of 3
RNA at W12 using a sensitive test with a lower detection limit of
15 IU/mL may be considered an appropriate timepoint for assessing virological response and identifying SVR and relapse in HIV/
HCV co-infected patients.
As is the case with HCV mono-infected patients, achieving an
undetectable serum HCV RNA at W24 is the current therapeutic
objective when treating HIV-infected patients with chronic HCV.8
However, studies in HCV mono-infected patients show that
testing HCV RNA at W12 may be considered an appropriate timepoint for assessing virological response.5,6,9 These studies have
found that a more sensitive assay can detect residual serum
HCV RNA in patients classified as having ETR with a less sensitive
assay, reclassifying them as early relapses.10 For this reason, a
low-sensitivity HCV RNA assay (detection limit 15 UI/mL) may
be an obstacle to early identification of patients with SVR.
Martinot-Peignoux et al.,6 evaluated 573 HCV mono-infected
patients who received a combination of PEG-INF/RBV and had
ETR to determine whether assessing serum HCV RNA at W12
using an assay with a detection limit of 5 –10 IU/mL was as
informative as at W24 for evaluating the SVR. At W12, serum
HCV RNA was undetectable in 409 patients, and 408 patients
had an SVR (PPV 99.7%, 95% CI 99.1% –100%). Aghemo et al.9
obtained similar results (PPV 100%) using two HCV RNA assays
with detection limits of 15 IU/mL and 50 IU/mL for 32 and 258
patients, respectively. In our study, using a HCV RNA commercially available assay with a detection limit of 15 IU/mL, no
cases of relapse were observed between W12 and W24, and
undetectable HCV RNA at W12 had a 100% PPV for SVR.
Information about the timing of HCV relapse in HIV/HCV
co-infected patients is scarce. In one study, carried out on 143
HIV/HCV co-infected patients treated with PEG-INF/RBV who
achieved ETR, all but 2 (45/47, 95.7%) relapses occurred before
W12.7 Phylogenetic analysis suggested that HCV re-infection
occurred in one patient, and the possibility that the second
patient might have been exposed again to the same source
that was the cause of her original infection could not be discounted. Despite the special characteristics of HIV/HCV
co-infected patients, our results suggest that HIV co-infection
does not seem to increase the risk of HCV relapse beyond W12
after completion of HCV therapy.
Early knowledge of the post-treatment response status in
patient therapy is likely to have a positive effect on the management of HCV patients. Reducing the post-treatment follow-up
period to 12 weeks from the current standard of 24 could lead
to a reduction in the costs associated with monitoring responses,
improve patient care and enable relapsed patients to pursue
alternative therapies earlier.
On the other hand, several studies have shown that the value
of measuring serum HCV RNA at W12 to assess SVR is independent of whether the patient is treated with standard or pegylated interferon (a2a or a2b), the interferon dose or whether
ribavirin is added to PEG-INF.5,6,10 However, whether the predictive value of measuring serum HCV RNA at W12 to assess SVR
also holds true for re-treating patients who have failed a previous
course of interferon-based therapy remains to be established.
In summary, our results show that undetectable HCV RNA
at W12 of the post-treatment follow-up has a 100% PPV (95%
CI 96.5% – 100%) for SVR, suggesting that testing for HCV RNA
at this point using a sensitive test with a detection limit of
JAC
Journal of Antimicrobial Chemotherapy Advance Access published October 11, 2011
J Antimicrob Chemother
doi:10.1093/jac/dkr439
Association between the IL28B genotype and hepatitis C viral kinetics
in the early days of treatment with pegylated interferon plus ribavirin
in HIV/HCV co-infected patients with genotype 1 or 4
Antonio Rivero-Juárez1, Ángela Camacho Espejo1, Inés Perez-Camacho2, Karin Neukam3, Antonio Caruz4,
José Antonio Mira3, Pilar Mesa4, Milagros Garcı́a-Lázaro1, Julián Torre-Cisneros1, Juan Antonio Pineda3
and Antonio Rivero1*
2
1
Infectious Diseases Unit, Maimonides Institute for Biomedical Research (IMIBIC), University Hospital Reina Sofia, Cordoba, Spain;
Internal Medicine Department, Hospital de Poniente, Almeria, Spain; 3Clinical Unit for Infectious Diseases, University Hospital de Valme,
Seville, Spain; 4Immunogenetics Unit, Department of Experimental Biology, Faculty of Sciences, University of Jaen, Jaen, Spain
*Corresponding author. Tel: +34-957012421/0034; Fax: +34-957011885; E-mail: [email protected]
Received 31 May 2011; returned 11 August 2011; revised 15 September 2011; accepted 19 September 2011
Downloaded from jac.oxfordjournals.org by guest on October 12, 2011
Objectives: To evaluate the effect of the interleukin 28B (IL-28B) genotype on hepatitis C virus (HCV) viral
kinetics in the first 4 weeks from start of treatment with pegylated interferon plus ribavirin (PEG-IFN/RBV) in
HIV/HCV co-infected patients.
Methods: HIV/HCV co-infected patients naive to PEG-IFN/RBV treatment were enrolled in a prospective study. HCV
RNA plasma viral loads were measured at baseline and at weeks 1, 2 and 4 after commencement of treatment.
Patients were grouped by HCV genotype (genotype 1/4 versus 3) and by IL-28B genotype (CC versus non-CC). Differences in viral load reduction were evaluated by IL-28B genotype between baseline, week 1, week 2 and week 4.
Results: One hundred and nineteen HIV/HCV patients were included in the study. HCV patients with genotype 1/4
and bearing the IL-28 CC genotype showed the greatest reductions in HCV RNA plasma levels between baseline and
weeks 1 (B-1), 2 (B-2) and 4 (B-4) than did those with non-CC genotypes (B-1: 1.06+0.89 versus 0.48+0.48 log IU/
mL, P¼0.009; B-2: 1.36+0.72 versus 0.77+0.66 log IU/mL, P¼0.01; and B-4: 1.91+0.64 versus
1.38+0.96 log IU/mL, P ¼0.03). However, differences between weeks 1 and 2 (W1-2) and between weeks 2 and
4 (W2-4) were not associated with the IL-28B genotype (W1-2: CC 0.48+0.42 versus non-CC 0.38+0.38 log IU/
mL, P¼0.62; W2-4: CC 0.32+0.23 versus non-CC 0.39+0.31 log IU/mL, P¼0.67). No differences in decline of
HCV RNA viral load were found in HCV genotype 3 patients.
Conclusions: The IL-28B genotype impacts on viral kinetics during the first week of treatment with PEG-IFN/RBV in
patients with HCV genotype 1/4.
Keywords: interleukin 28B, HIV, HCV, pharmacogenetics, viral kinetics
Introduction
The hepatitis C virus (HCV) is the cause of one of the most
common blood-borne infections worldwide.1 It is considered to
be the leading cause of cirrhosis and liver cancer in Europe and
the USA.1 In HIV co-infected patients, the current standard of
care is pegylated interferon (PEG-IFN) plus ribavirin (PEG-IFN/
RBV), although rates of sustained virological response (SVR)
vary significantly according to virus, disease and a host of
other related factors.1
Several studies have provided information about the clinical
applicability of early viral kinetics in predicting SVR. Rapid virological response (RVR), defined as an undetectable serum HCV RNA
level at week 4 of treatment with PEG-IFN/RBV, is a reliable
predictor of SVR.2 At the same time, it has been demonstrated
that polymorphisms near the interleukin 28B (IL-28B) gene on
chromosome 19 predict SVR and RVR in both HCV mono-infected
and HIV/HCV co-infected patients carrying genotype 1/4 and
treated with PEG-IFN/RBV.3,4
Several studies suggest that the effect of the IL-28B genotype on HCV viral kinetics can be seen in the first few days
from start of treatment.4,5 However, there is limited information
about the IL-28B effect after treatment has started, and no
data about its effect on HIV/HCV co-infected patients.4,5 The
objective of this study was to evaluate the effect of the
IL-28B genotype on HCV viral kinetics in the first few weeks
after starting treatment with PEG-IFN/RBV in HIV/HCV
co-infected patients.
# The Author 2011. Published by Oxford University Press on behalf of the British Society for Antimicrobial Chemotherapy. All rights reserved.
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1 of 4
Methods
Table 1. General population characteristics
Patients
Characteristics
Caucasian HIV-infected patients with chronic hepatitis C, naive to HCV
treatment and receiving a PEG-IFN/RBV combination therapy, were
included in this prospective study. The criteria used to determine
hepatitis C therapy were in accordance with international guidelines.
Host, clinical and virological characteristics were collected.
Treatment regimens
All individuals were treated with either PEG-IFN-a2a or PEG-IFN-a2b, at
doses of 180 mg or 1.5 mg/kg per week, respectively, in combination
with a weight-adjusted dose of oral ribavirin (1000 mg/day for ,75 kg,
1200 mg/day for ≥75 kg).
N
Male, n (%)
Age (years), mean+SD
Plasma HCV RNA load measurements were taken at baseline and at weeks
1, 2 and 4 using a quantitative PCR assay (Cobas TaqMan, Roche Diagnostic
Systems Inc., Pleasanton, CA, USA) with a detection limit of 15 IU/mL.
The rs129679860 single-nucleotide polymorphism (SNP) was genotyped
using a custom TAQMAN genotyping assay (Applied Biosystems) on DNA
isolated from whole blood samples. The DNA was genotyped according
to manufacturer’s instructions on an MX3005 thermocycler using
MXpro software (Stratagene). Researchers responsible for genotyping
procedures were unaware of other patient data. The IL-28B genotype
was defined as CC or non-CC (TT/CT).
Continuous variables are expressed as mean+standard deviations or
medians (Q1– Q3), and were analysed by Student’s t-test or the Mann–
Whitney U-test. Categorical variables are expressed as the number of
cases (percentage). Frequencies were compared using the x2 test or
Fisher’s exact test. Significance was defined as a P value ,0.05. The
subpopulation of patients with HCV genotype 4 was evaluated together
with the HCV genotype 1 subpopulation. Reductions in plasma HCV
RNA were evaluated by the IL-28B genotype between baseline, week 1,
week 2 and week 4. Patients who presented an undetectable HCV viral
load at any timepoint during the study were excluded when calculating
HCV RNA reduction at any later point. Patients were classified as slow
or fast responders, according to whether the reduction of HCV RNA viral
load was above or below the median. The decline in HCV RNA was
calculated according to the stage of liver fibrosis, HCV baseline viral
load and PEG-IFN type. The analysis was performed using the SPSS
statistical software package, version 15.0 (SPSS).
Ethical aspects
The study was designed and performed according to the Helsinki
Declaration and approved by the ethics committee of the Reina Sofı́a
University Hospital, Cordoba, Spain. All patients provided written
informed consent before participating in this study.
Results
One hundred and nineteen HIV/HCV co-infected patients were
included in the study. The baseline characteristics of the patients
are summarized in Table 1.
2 of 4
41.2+2,6
113 (94.9)
CD4 (cells/mm3), mean+SD
558+45
Transmission, n (%)
IDU
heterosexual
117 (98.3)
2 (1.7)
5.98+0.2
PEG-IFN, n (%)
2a
2b
93 (78.2)
26 (21.8)
HCV genotype, n (%)
1
4
3
65 (54.7)
16 (13.4)
38 (31.9)
IL-28B genotype, n (%)
CC
CT
TT
49 (41.1)
22 (18.6)
48 (40.3)
Liver fibrosis stage, n (%)
F0-F2
F3-F4
51 (42.9)
68 (57.1)
Log HCV RNA IU/mL baseline by HCV genotype, mean+SD
genotype 1/4 HCV
genotype 3 HCV
6.13+0.85
5.76+0.79
Log HCV RNA IU/mL baseline by IL28B genotype, mean+SD
IL-28B CC
6.15+0.83
IL-28B non-CC
5.9+0.9
HAART, highly active antiretroviral treatment; IDU, intravenous drug user.
HCV genotype 1/4 patients carrying the IL-28 CC genotype
showed a greater reduction in plasma HCV RNA levels between
baseline and weeks 1 (B-1), 2 (B-2) and 4 (B-4) than did non-CC
genotype carriers (B-1: 1.06+0.89 versus 0.48+0.48 log IU/mL,
P ¼ 0.009; B-2: 1.36+0.72 versus 0.77+0.66 log IU/mL, P ¼ 0.01;
and B-4 1.91+0.64 versus 1.38+0.96 log IU/mL, P ¼ 0.03)
(Figure 1a). However, no differences in HCV RNA reduction were
found by the IL-28B genotype between weeks 1 and 2 (CC
0.48+0.42 versus non-CC 0.38+0.38 log IU/mL, P ¼ 0.62) or
between weeks 2 and 4 (CC 0.32+0.23 versus non-CC
0.39+0.31 log IU/mL, P ¼ 0.67) in HCV genotype 1/4 patients.
In HCV genotype 3 patients, there were no observable
differences of viral load reduction found between B-1, B-2 or
B-4, irrespective of whether the IL-28B genotype was CC or
non-CC (B-1: 1.81+1.06 versus 1.65+0.93 log IU/mL, P¼ 0.64;
B-2: 2.73+0.88 versus 3.15+1.4 log IU/mL, P ¼ 0.28; and B-4:
3.75+0.88 versus 4.04+1.06 log IU/mL, P ¼ 0.45) (Figure 1b).
Determination of the IL-28B genotype
97 (81.5)
HAART, n (%)
Log HCV RNA baseline, mean+SD
119
JAC
IL28B CC genotype is associated with a greater viral load reduction
Baseline
0
Week 1
P = 0.009
HCV load (log IU/mL)
0.5
1
Week 2
Week 4
P = 0.01
P = 0.03
2
2.5
3
4
Baseline
0
Week 1
Week 2
Week 4
0.5
1.5
3.5
(b)
CC
Non-CC
4.5
HCV load (log IU/mL)
(a)
1
P = 0.64
1.5
2
P = 0.38
2.5
3
3.5
4
CC
P = 0.45
Non-CC
4.5
Figure 1. Mean reduction in viral load from baseline according to IL-28B genotype in HCV genotype 1/4 (a) and genotype 3 (b) patients.
Discussion
In this study, the host IL-28B genotype was a pre-treatment
predictor of HCV RNA kinetics in HIV/HCV co-infected patients
carrying genotype 1/4 and who started therapy with PEG-IFN/
RBV. The IL-28B CC genotype was associated with a greater
decline in on-treatment viral load compared with patients who
harboured the IL-28B non-CC type. This difference was observed
as early as the first week from start of therapy and was maintained during the first 4 weeks of treatment.
As previously reported, a small but not clinically significant
difference in median plasma HCV RNA load at baseline has
been noted for the IL-28B genotype, with higher levels in CC
patients.6 It has been suggested that, as the product of the
IL-28B gene is IFN-l3, patients harbouring the IL-28B
rs12979860 allele C might exhibit lower immune activity, permitting higher HCV replication.6 Consequently, such patients might
retain an enhanced susceptibility to exogenous PEG-IFN-based
therapy.6
Viral decline during IFN therapy is biphasic. The first phase
occurs during the first 72 h from start of therapy, with a slower
second phase.7 In one clinical trial, HCV viral load was measured
at baseline and 24 h following a test dose of 9 MU IFN-a2a, and
HCV RNA reduction after 24 h was used to randomly stratify
patients carrying genotype 1.5 The decline in plasma HCV RNA
load after 24 h was much greater in IL-28B CC genotype than
in non-CC genotype carriers.5 Similar data were obtained for
patients carrying genotype 4.5 In another study, differences in
HCV RNA load reduction between IL-28B CC, CT and TT genotypes
were detectable at week 2, the earliest timepoint evaluated.4 In
our study we found differences in HCV RNA load reduction
between IL-28B CC and non-CC genotypes from baseline at
every timepoint analysed, although no difference in HCV RNA
load reduction was found between week 1 and week 2, or
week 2 and week 4. This is an important issue because it
implies that the effect of the IL-28B genotype occurs during
the first phase of viral decay, thought to be due to the process
of free virion clearance and the inhibition of new viral production
rather than the slower second phase, whose gradient is thought
to mirror the process of infected cell clearance.
The fastest reductions in viral load correlated with increased
rates of the appropriate on-treatment virological endpoint,
such as RVR or complete early virological response.5 At the
same time, RVR has been demonstrated to be a critical predictor
of SVR, independent of the host IL-28B genotype.2 Our observations suggest that the major effect of this polymorphism is
to increase the rate of early viral decline, leading to a higher
RVR rate.
We found that the magnitude of viral decline for patients
carrying genotype 1 or 4 was lower than for genotype 3 at all
timepoints in the study. Differences in viral load reduction
across the HCV genotypes were detectable as early as week 1,
confirming that genotype is the most important factor for
predicting an early response to antiviral therapy.8
Data concerning the relevance of the IL-28B genotype in
patients carrying HCV genotype 3 are emerging. Mangia
et al.9 observed that genotype 2/3 patients with the IL-28B
CC genotype who failed to achieve RVR were more likely to
achieve SVR than their non-CC-type counterparts. In our
study, the host IL-28B genotype in genotype 3 carriers was
not found to have a significant impact on HCV viral kinetic
response in the first few days of treatment. On-treatment
viral kinetics provides a direct measurement of treatment
response. The virological response to treatment for HCV genotype 3 is usually very strong and early, and this might limit
the advantage conferred by a favourable IL-28B genotype.
3 of 4
Median HCV RNA reductions for HCV genotype 1/4 patients at
B-1, B-2 and B-4 were 0.37 log IU/mL (0.11– 0.44), 0.79 log IU/
mL (0.38– 0.91) and 1.28 log IU/mL (0.89–1.37), respectively.
The IL-28B CC genotype was more common in patients who
were fast responders than in slow responders at all timepoints
analysed [B-1: 39/51 (76.4%) versus 10/58 (17.2%), P,0.001;
B-2: 42/54 (77.7%) versus 7/55 (12.7%), P,0.001; and B-4:
42/54 (77.7%) versus 7/55 (12.7%), P,0.001].
A total of 37 (31.1%) patients attained RVR, and at significantly lower rates for genotype 1/4 than for genotype 3 [16/81
(19.7%) versus 21/38 (55.2%), P ¼ 0.002]. Among patients
bearing genotype 1/4, the RVR rate was significantly higher for
IL-28B CC genotypes than for non-CC [9/31 (29.03%) versus
7/50 (14%), P¼ 0.01]. However, in patients bearing genotype 3,
there were no observable differences in RVR rate between
IL-28B CC and non-CC genotypes [10/18 (55%) versus 11/20
(55%), P¼ 0.985].
No differences in HCV RNA reduction were found by liver
fibrosis stage, baseline viral load or PEG-IFN type.
A better-powered cohort is necessary to find statistically
significant associations.
In summary, in HIV co-infected patients, SNP rs12979860 in
the region of the IL-28B gene has an impact on early viral
kinetics in response to PEG-IFN/RBV therapy for chronic hepatitis
C caused by HCV genotypes 1 and 4. At present, as with viral
genotype, information about IL-28B status is being used to
inform patients about the likelihood of obtaining a response to
PEG-IFN/RBV combination therapy. Whether determining viral
kinetics during the first week from start of treatment will be a
better predictor of response to HCV combination therapy, and
whether this should be used for making decisions about
treatment in such patients, remains to be studied.
Funding
Transparency declarations
A. R. has received consulting fees from Bristol-Myers Squibb, Abbott,
Gilead, Roche and Boehringer Ingelheim. J. A. P. has received consulting
fees from GlaxoSmithKline, Bristol-Myers Squibb, Abbott, Gilead, Merck
Sharp & Dohme, Janssen-Cilag and Boehringer Ingelheim. They have
received research support from GlaxoSmithKline, Roche, Bristol-Myers
Squibb, Schering-Plough, Abbott and Boehringer Ingelheim, and lecture
4 of 4
References
1 Izumi N, Asahina Y, Kurosaki M. Predictors of virological response to a
combination therapy with pegylated interferon plus ribavirin including
virus and host factors. Hepat Res Treat 2010; 2010: 703602.
2 Mira JA, Valera-Bestard B, Arizcorreta-Yarza A et al. Rapid virological
response at week 4 predicts response to pegylated interferon plus
ribavirin among HIV/HCV co-infected patients. Antivir Ther 2007; 12:
523–9.
3 Pineda JA, Caruz A, Rivero A et al. Prediction of response to pegylated
interferon plus ribavirin by IL28B gene variation in patients coinfected
with HIV and hepatitis C virus. Clin Infect Dis 2010; 51: 788– 95.
4 Thompson AJ, Muir AJ, Sulkowski MS et al. Interleukin-28B
polymorphism improves viral kinetics and is the strongest pretreatment
predictor of sustained virologic response in genotype 1 hepatitis C virus.
J Gastroenterol 2010; 139: 120–9.
5 Stättermayer AF, Stauber R, Hofer H et al. Impact of IL28B genotype on
early and sustained virologic response in treatment-naı̈ve patients with
chronic hepatitis C. Clin Gastroenterol Hepatol 2011; 9: 344– 50.
6 Labarga P, Soriano V, Caruz A et al. Association between IL28B gene
polymorphism and plasma HCV-RNA levels in HIV/HCV-co-infected
patients. AIDS 2011; 25: 761–6.
7 Arends JE, Cohen S, Baak LC et al. Plasma HCV-RNA decline in the
first 48 h identifies hepatitis C virus mono-infected but not HCV/
HIV-coinfected patients with an undetectable HCV viral load at week 4
of peginterferon-alfa-2a/ribavirin therapy. J Viral Hepat 2009; 16:
867–75.
8 Fried MW. Viral factors affecting the outcome of therapy for chronic
hepatitis C. Rev Gastroenterol Disord 2004; 4 Suppl 1: S8– 13.
9 Mangia A, Thompson AJ, Santoro R et al. IL28B polymorphism
determines treatment response of patients with hepatitis C genotypes
2 or 3 who do not achieve a rapid virologic response. Gastroenterology
2010; 139: 821–7.
This work was partly supported by grants from the Fundación Progreso y
Salud, Consejerı́a de Salud de la Junta de Andalucı́a (grants for health
research projects, references 0036/2010, PI-0247-2010 and PI-0208
and 0124/2008) and from the Spanish Health Ministry (ISCIII-RETIC
RD06/006, and projects PI10/0164 and PI10/01232). A. R. is the recipient
of a research extension grant from the Fundación Progreso y Salud,
Consejerı́a de Salud of the Junta de Andalucı́a (reference
AI-0011-2010). J. A. P. is the recipient of an extension grant from the
Fundación Progreso y Salud of the Consejerı́a de Salud of the Junta
de Andalucı́a (reference AI-0021). K. N. is the recipient of a Sara Borrell
postdoctoral perfection grant from the Instituto de Salud Carlos III
(SCO/523/2008).
fees from GlaxoSmithKline, Roche, Abbott, Bristol-Myers Squibb, Boehringer Ingelheim and Schering-Plough. The remaining authors have no conflicts of interest to declare.
LDLr genotype modifies the impact of IL28B on HCV
viral kinetics after the first weeks of treatment with
PEG-IFN/RBV in HIV/HCV patients
Antonio Rivero-Juareza,b, Angela Camachoa,b, Antonio Caruzc,
Karin Neukamd, Rafael Gonzalezb,e, Federico A. Di Lellod,
Ines Perez-Camachof, Pilar Mesac, Julian Torre-Cisnerosa,b,
José Peñab,e, Juan A. Pinedad and Antonio Riveroa,b
Objective: To evaluate the effect of low-density lipoprotein receptor (LDLr) and IL28B
genotypes on hepatitis C virus (HCV) viral kinetics in the first 4 weeks of treatment with
pegylated-interferon (PEG-IFN)/ribavirin (RBV) in HIV patients co-infected with HCV
genotype 1.
Methods: HIV patients co-infected with HCV genotype 1 and naı̈ve to PEG-IFN/RBV
treatment were enrolled in a prospective study. HCV RNA viral loads were measured at
baseline and at weeks 1, 2 and 4 after start of therapy. Differences in viral load decline
were evaluated for IL28B (CC versus non-CC) and LDLr (CC versus non-CC) genotypes
between baseline and weeks 1, 2 and 4. Additionally, the effect of LDLr genotype on
HCV viral decline in IL28B CC genotype patients (CC/CC versus CC/non-CC) was
analyzed.
Results: Eighty-seven HIV/HCV genotype 1 co-infected patients were included in the
study. Patients carrying the LDLr-CC or IL28B-CC genotypes showed greater HCV viral
decline than those with IL28B non-CC or LDLr non-CC genotypes at every time-point
analyzed. CC/CC patients had higher rapid virological response (RVR) rates than
CC/non-CC patients (41.2 versus 13.3%; P < 0.001). Moreover, at all time points,
the CC/CC pattern was associated with greater HCV viral decline than the CC/non-CC
genotype (week 1: 1.18 0.51 versus 0.31 0.29, P ¼ 0.041; week 2: 1.55 0.81
versus 0.93 0.73, P ¼ 0.032; week 4: 2.23 1.1 versus 1.5 0.94, P ¼ 0.039).
Conclusion: The LDLr genotype impacts on viral kinetics during the first days of starting
treatment with PEG-IFN/RBV in HIV/HCV genotype 1 co-infected patients, and
modifies the impact of IL28B on HCV viral decay.
ß 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins
AIDS 2012, 26:1009–1015
Keywords: hepatitis C virus, HIV, IL28B, low-density lipoprotein-receptor,
pegylated-interferon, ribavirin, viral kinetics
Introduction
The IL28B genotype is associated with greater viral
decline in the hepatitis C virus (HCV) during the first
weeks of treatment with pegylated-interferon (PEG-IFN)
and ribavirin (PEG-IFN/RBV) in both HCV monoinfected and HIV/HCV co-infected patients bearing
HCV genotype 1 [1–4]. As a result, a more rapid viral
a
Unit of Infectious Diseases, Hospital Universitario Reina Sofia, Cordoba, Spain, bMaimónides Institute for Biomedical Research
(IMIBIC), Córdoba, cImmunogenetics Unit, Faculty of Sciences, Universidad de Jaén, Jaen, dUnit of Infectious Diseases and
Microbiology, Hospital Universitario de Valme, Seville, eInmunology Service, Hospital Universitario Reina Sofia, Cordoba, and
f
Unit of Infectious Disease, Hospital de Poniente, El Ejido, Spain.
Correspondence to Antonio Rivero, Hospital Universitario Reina Sofia de Córdoba, Edificio Provincial, Hospital de dı́a de
Enfermedades Infecciosas, Avd. Menendez Pidal s/n. 14004, Cordoba, Spain.
Tel: +34 9570 12421; fax: +34 9570 11885; e-mail: [email protected]
Received: 19 January 2012; revised: 7 February 2012; accepted: 14 February 2012.
DOI:10.1097/QAD.0b013e3283528b1c
ISSN 0269-9370 Q 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins
1009
Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
1010
AIDS
2012, Vol 26 No 8
decline leads to a better response to treatment, with better
rapid virological response (RVR) and sustained virological response (SVR) rates [5,6].
Hepatitis C virus may play a significant role in the serum
lipid profile of patients with chronic HCV infection [7,8].
HCV viremia seems to be associated with lower serum
cholesterol and triglyceride levels [9,10]. A high LDL
cholesterol (LDL-C) level has been observed to be an
independent predictive factor for response to current
standards of care in HCV treatment, in both HCVinfected and HIV/HCV co-infected patients [11,12].
There is, however, no clear explanation for this.
Patients carrying the IL28B-CC genotype have been
reported as having higher levels of LDL-C than those with
the IL28B-non-CC genotype [5], suggesting that the
beneficial effect of the IL28B genotype could be related to
lipid metabolism, specifically LDL-C metabolism. In this
respect, our group has reported that variations in the lowdensity lipoprotein receptor (LDLr) gene are associated
with higher SVR rates in HIV/HCV genotype 1/4 coinfected patients and significantly increase the favorable
impact of the IL28B CC genotype on SVR [13].
Here we analyze the effect of LDLr, and its association
with the IL28B genotype, on HCV viral decline during
the first weeks of treatment with PEG-IFN/RBV in
HIV/HCV co-infected patients bearing genotype 1.
Methods
Patients
Caucasian HIV-infected patients with chronic hepatitis C,
naive to HCV treatment and receiving a PEG-IFN/RBV
combination therapy, were included in this prospective
study. The criteria used to determine hepatitis C therapy
followed international guidelines [14]. Host, clinical and
virological characteristics were collected. Fibrosis stage was
determined by biopsy or liver transient elastography
(FibroScan, Echosen, Paris). Significant fibrosis was
defined as a METAVIR fibrosis score of F3-F4 in liver
biopsy or a liver stiffness value of at least 8.9 kPa.
Treatment regimens
All individuals were treated with either PEG-IFN a2a or
PEG-IFN a2b, at doses of 180 mg or 1.5 mg/kg per week,
respectively, in combination with a weight-adjusted dose of
oral ribavirin (1000 mg/day for <75 kg, 1200 mg/day for
75 kg), in accordance with international guidelines [14].
Plasma HCV RNA load measurements were conducted
at baseline and at weeks 1, 2 and 4, using a quantitative
PCR assay (Cobas TaqMan; Roche Diagnostic Systems
Inc., Pleasanton, California, USA), with detection limit
of 15 IU/ml.
Single-nucleotide polymorphism genotyping
DNA was extracted using the automated MagNA Pure
DNA extraction method (Roche Diagnostics Corporation, Indianapolis, Indiana, USA). Single-nucleotide
polymorphisms (SNPs) rs14158 in the 30 UTR of the
LDLR gene, and rs129679860, located 3 kilobases
upstream of the IL28B, and in strong linkage disequilibrium with a nonsynonymous coding variant in the
IL28B gene (213A > G, K70R; rs81031142) (0), were
genotyped. Genotyping was carried out using a custom
TAQMAN assay (Applied Biosystems, Foster City,
California, USA) on DNA isolated from whole blood
samples, using a Stratagene MX3005 thermocycler with
MXpro software (Stratagene, La Jolla, California, USA),
according to manufacturer’s instructions. The researchers
responsible for genotyping were blinded to other patient
data. The IL28B and LDLr genotypes were defined as CC
or non-CC (TT/CT).
Continuous variables were expressed as mean standard
deviation (SD) or median (Q1–Q3) and were analyzed
by Student’s t-test, Mann–Whitney U-test or Kruskal–
Wallis test. Categorical variables were expressed as
number of cases (percentage). Frequencies were compared using the x2 test or Fisher’s exact test. Significance
was defined as a P value of less than 0.05. Plasma HCV
RNA levels were analyzed by LDLr and IL28B genotypes
between baseline and week 1, week 2 and week 4.
Additionally, we analyzed the effect of the LDLr genotype
on HCV viral decline in IL28B-CC patients (CC/CC
versus CC/non-CC) and IL28B non-CC patients (nonCC/CC versus non-CC/non-CC).
Patients were classified as slow or fast responders according
to whether HCV RNA viral load reduction was above or
below the median HCV RNA load at the corresponding
time-point. The relation between RNA HCV decline and
liver fibrosis stage, baseline HCV viral load and PEG-IFN
type was evaluated. The analysis was performed using the
SPSS statistical software package, version 18.0 (IBM
Corporation, Somers, New York, USA).
Ethical aspects
The study was designed and performed according to the
Helsinki Declaration and approved by the ethics
committee of the Reina Sofı́a University Hospital,
Cordoba, Spain. All patients provided written informed
consent before participating in this study.
Results
Baseline characteristics and IL28B and lowdensity lipoprotein receptor distributions
Eighty-seven HIV/HCV genotype 1 co-infected patients
were included in this prospective study. Baseline patient
characteristics, stratified according to IL28B and LDLr
LDLr modifies the impact of the IL28B genotype Rivero-Juarez et al.
1011
Table 1. Baseline population characteristics stratified according to IL28B and LDLr genotypes.
Characteristics
IL28B
CC/LDLR CC
IL28B
CC/LDLR non-CC
IL28B
non-CC/LDLR CC
IL28B
non-CC/LDLR non-CC
P
N
Age (years), mean SD
Male, n (%)
CD4 cell count (cells/ml), mean SD
Prior AIDS diagnosis, n (%)
Undetectable HIV viral load, n (%)
Significant liver fibrosis, n (%)
Liver cirrhosis, n (%)
PEG-IFN a2a, n (%)
Use of HAART, n (%)
17
41.6 3.2
12 (70.5)
549 249
6 (35.3)
16 (94.1)
12 (70.5)
5 (29.4)
11 (64.7)
17 (100)
15
40.8 3.9
10 (66.6)
527 298
2 (13.3)
14 (93.3)
12 (80)
5 (33.3)
13 (86.6)
14 (93.3)
32
41.1 4.3
24 (75)
541 241
6 18.7)
30 (93.7)
24(75)
8 (25)
22 (68.7)
30 (93.7)
23
42.7 4.2
16 (69.5)
532 284
7 (30.4)
20 (86.9)
17 (73.9)
7 (30.4)
16 (69.5)
21 (91.3)
0.73
0.847
0.81
0.21
0.87
0.46
0.61
0.76
0.94
HAART, highly active antiretroviral treatment; PEG-INF, pegylated interferon; SD, standard deviation.
genotypes, are shown in Table 1. The IL28B genotype
distribution was: CC in 32 (36.8%) patients, CT in 46
(52.8%) patients and TT in nine (10.4%) patients. The
distribution of LDLr was: CC in 52 (59.8%) patients, CT
in 34 (39.1%) patients and TT in 1 (1.1%) patient. Among
IL28B-CC patients, 17 (53.1%) carried the LDLr-CC
genotype and 15 (46.9%) the LDLr non-CC genotype.
Among IL28B non-CC patients, 32 (58.2%) carried the
LDLr-CC and 23 (41.8%) the LDLr non-CC genotypes.
The IL28B-CC genotype was associated with a higher
baseline HCV viral load than the non-CC genotype
(6.17 0.77 versus 5.89 0.84; P ¼ 0.032). In our study,
the LDLr-CC genotype was not associated with lower
baseline HCV viral loads (6.13 0.919 versus 6.2 0.73;
P ¼ 0.349).
Rapid virological response rate by IL28B and
low-density lipoprotein receptor genotypes
Fourteen (16.1%) patients achieved RVR. Patients with
the IL28B-CC genotype presented a higher RVR rate [9/
32 (28.1%) versus 5/55 (9.1%); P ¼ 0.023]. The LDLrCC genotype, on the contrary, was not associated with
achieving RVR [10/52 (19.2%) versus 4/35 (11.4%);
P ¼ 0.265]. The analysis of RVR rates according to
IL28B/LDLr genotypes showed that CC/CC patients
had higher RVR rates [CC/CC: 7/17 (41.2%); CC/nonCC: 2/15 (13.3%); non-CC/CC: 4/32 (12.5%); nonCC/non-CC: 1/23 (4.3%); P < 0.001]. No differences in
RVR rate (P ¼ 0.423) were found between non-CC/CC,
CC/non-CC and non-CC/non-CC patients.
Rapid responders rate
Median (Q1-Q3) HCV viral decline from baseline to
week 1, week 2 and week 4 was 0.37 (0.12–0.94), 0.75
(0.32–1.57) and 1.25 (0.75–2.51) log IU/ml, respectively. The LDLr-CC genotype was more frequently
found in rapid responders than the non-CC genotype at
week 1 [23/52 (44.2%) versus 7/35 (14.3); P ¼ 0.014],
week 2 [25/52 (48.1%) versus 9/35 (25.7%); P ¼ 0.028]
and week 4 [27/52 (51.9%) versus 9/35 (25.7%);
P ¼ 0.015]. Similarly, rapid responders were more
common among patients with the IL28B-CC rather
than the non-CC genotype, at week 1 [16/32 (50%)
versus 13/55 (23.6%); P ¼ 0.01], week 2 [19/32 (59.4%)
versus 16/55 (29%); P ¼ 0.004] and week 4 [20/32
(62.5%) versus 16/55 (29%); P ¼ 0.002].
The IL28B/LDLr distribution of rapid responders at
every time-point analyzed is shown in Table 2. The
CC/CC genotype had higher rates of rapid responders
than CC/non-CC, non-CC/CC and non-CC/non-CC
genotypes at week 1 (P ¼ 0.003), week 2 (P ¼ 0.001) and
week 4 (P ¼ 0.001), and there were no differences in the
rate of rapid responders between CC/non-CC, non-CC/
CC and non-CC/non-CC patients at every time-point
analyzed (week 1, P ¼ 0.49; week 2, P ¼ 0.32; week 4,
P ¼ 0.32).
Hepatitis C virus viral decline
There were 16 (18.4%) patients whose baseline HCV
viral load was more than 600 000 IU/ml, and the degree
of HCV viral decline in these patients was less, although
Table 2. Relation between IL28B/LDLr genotypes and rapid responders’ rate (compared by x2 test).
Rapid responders
Genotype
Week 1
P
Week 2
P
Week 4
P
CC/CC
CC/non-CC
Non-CC/CC
Non-CC/non-CC
12/17 (70.6%)
3/15 (20%)
7/29 (24.1%)
4/20 (20%)
0.002
14/17 (82.3%)
4/15 (26.3%)
9/32 (28.1%)
5/23 (21.7%)
0.001
14/17 (82.3%)
4/15 (26.3%)
9/32 (28.1%)
5/23 (21.7%)
0.001
2012, Vol 26 No 8
not statistically significant, than in those with a low HCV
baseline viral load at week 1 (0.56 0.79 versus
0.59 0.39; P ¼ 0.871), week 2 (0.86 0.64 versus
1.1 0.87; P ¼ 0.529) and week 4 (1.32 1.05 versus
1.68 1.11; P ¼ 0.233). Likewise, there were no
differences in HCV viral decline between patients
without or with significant liver fibrosis (week 1:
0.61 0.81 versus 0.59 0.58, P ¼ 0.877; week 2:
1.16 0.89 versus 0.92 0.99, P ¼ 0.305; week 4:
1.87 1.24 versus 1.56 1.25, P ¼ 0.318) or between
PEG-IFN a2a and PEG-IFN a2b (week 1: 0.67 0.8
versus 0.63 0.68, P ¼ 0.577; week 2: 1.1 0.97 versus
0.89 0.76, P ¼ 0.118; week 4: 1.96 1.25 versus
1.81 1.01, P ¼ 0.175).
Patients carrying the IL28B-CC genotype showed
greater HCV viral decline from baseline than those with
the IL28B non-CC genotype at week 1 (0.88 0.6 versus
0.35 0.54; P ¼ 0.006), week 2 (1.37 0.87 versus
0.54 0.62; P ¼ 0.017) and week 4 (2.1 0.75 versus
1.14 0.91; P ¼ 0.026). However, we did not find any
differences of HCV viral decline among IL28B genotypes
between weeks 1 and 2 (CC 0.45 0.4 versus non-CC
0.33 0.37; P ¼ 0.295) or weeks 2 and 4 (CC
0.69 0.61 versus non-CC 0.58 0.68; P ¼ 0.571).
Patients carrying the LDLr-CC genotype showed greater
HCV viral decline than those with the non-CC genotype
at week 1 (0.73 0.836 versus 0.37 0.54 log IU/ml;
P ¼ 0.042), week 2 (1.16 0.97 versus 0.68 0.81;
P ¼ 0.027) and week 4 (1.81 1.27 versus 1.3 1.14;
P ¼ 0.06) (Fig. 1). There was no association between
LDLr genotypes and HCV viral decline between weeks 1
and 2 (CC 0.38 0.39 versus non-CC 0.35 0.38;
P ¼ 0.796) or weeks 2 and 4 (CC 0.64 0.7 versus nonCC 0.57 0.59; P ¼ 0.743).
Baseline
0
Week 1
Week 2
Baseline
0
HCV log IU/ml viral decline
AIDS
HCV log IU/ml viral decline
1012
Week 1
Week 2
Week 4
0,5
1
1,5
2
rs 129679860 CC/rs 14158 CC
rs 129679860 CC/rs 14158 non-CC
rs 129679860 non-CC/rs 14158 CC
rs 129679860 non-CC/rs 14158 non-CC
2,5
Fig. 2. HCV viral decline between IL28B and LDLr genotypes (rs12967860/rs14158) during the first weeks of treatment (compared using the Kruskal–Wallis test).
Patients carrying the CC/CC genotype showed greater
viral decline at week 1 (CC: 1.18 0.51; CC/non-CC:
0.31 0.29; non-CC/CC: 0.51 0.53; non-CC/nonCC: 0.39 0.41, P ¼ 0.041), week 2 (CC: 1.55 0.81;
CC/non-CC: 0.93 0.73; non-CC/CC: 0.94 0.69;
non-CC/non-CC: 0.74 0.56, P ¼ 0.032) and week 4
(CC: 2.23 1.1; CC/non-CC: 1.5 0.94; non-CC/
CC: 1.57 1.12; non-CC/non-CC: 1.19 0.92,
P ¼ 0.039) (Fig. 2). No differences in HCV RNA viral
decline were found between CC/non-CC, non-CC/CC
and non-CC/non-CC patients at week 1 (P ¼ 0.42),
week 2 (P ¼ 0.317) or week 4 (P ¼ 0.18). No differences
in HCV viral decline were observed by IL28B/LDLr
genotypes between weeks 1 and 2 (CC/CC 0.46 0.38;
CC/non-CC 0.4 0.37; non-CC/CC 0.36 0.29;
non-CC/non-CC 0.29 0.33 P ¼ 0.55) or weeks 2
and 4 (CC/CC 0.52 0.39; CC/non-CC 0.47 0.58;
non-CC/CC 0.42 0.34; non-CC/non-CC 0.39 0.45
P ¼ 0.69).
Week 4
Discussion
0,5
The study found that the LDLr genotype was a
pretreatment predictor of HCV kinetics in HIV/HCV
co-infected patients bearing genotype 1 starting therapy
with PEG-IFN/RBV, and that it modified the effect of
the IL28B genotype on HCV viral decline.
1
1,5
2
rs14158 CC
rs14158 non-CC
2,5
Fig. 1. HCV viral decline between the LDLr genotype
(rs14158) during the first weeks of treatment with PEGIFN/RBV (compared using Student’s t test).
Low-density lipoprotein receptor seems to play an
important role in HCV cell entry [15]. Recent data
show that HCV entry is a complex multistep process
involving the presence of several factors [16,17]. HCV
enters the hepatocyte in the form of HCV lipo-viral
particles (HCV-LVP), using cell surface LDLr, glycosaminoglycans, such as heparan sulfate, and scavenger
receptors class B type I (SR-BI) as initial attachment
factors [15–17]. LDLr and SR-BI recognize the LDL and
HDL, respectively, of the LVP [16,17]. The virus attached
to the hepatocyte subsequently interacts with cellular
protein to provide the final key to HCVentry [18]. In this
way, variations in the LDLr gene determine HCV
attachment and entry.
It has been observed that patients carrying the LDLr-CC
genotype have lower HCV viral loads than non-CC
patients [13], so that the beneficial impact of LDLr gene
variations on treatment response could be the reduction
in baseline HCV viral load, an independent predictor of
treatment response [19]. Our study did not find this
relation, although results showed that the LDLr-CC
genotype was associated with a greater decline in ontreatment viral load when compared with patients
harboring LDLr non-CC. This difference was observed
as early as the first week from start of therapy and was
maintained during the first 4 weeks of treatment. We also
found differences in reduction of HCV RNA load from
baseline between LDLr-CC and non-CC genotypes at
every time-point analyzed, although none between week
1 and week 2, or between week 2 and week 4. This is an
important issue because it suggests that the beneficial
effect of the LDLr genotype is due, at least in part, to its
initial effect on viral kinetics and that it occurs during the
first phase of viral decay.
At the same time, our study confirms the beneficial
impact of IL28B on HCV viral decline during the first
week of treatment with PEG-IFN/RBV. Our results
match those for HCV monoinfected patients, as well as
those previously demonstrated by our group for HCV/
HIV co-infected patients [1–3]. Our findings suggest that
the IL28B genotype has an impact on HCV/HIV coinfected patients only during the first phase of HCV viral
kinetics, although it has recently been reported that the
IL28B genotype was associated with greater viral decline
in HCV monoinfected patients during the first and
second phases of HCV viral kinetics [4]. Studies using a
more powerful cohort of HIV/HCV co-infected patients
are needed to clarify this point. The exact mechanism by
which IL28B exerts an influence on early HCV viral
kinetics is unclear. One suggestion is that viral infection
induces the synthesis of this cytokine with antiviral
activity. Like IFN-a, IFN-l stimulates the Janus kinase/
signal transducers and activators of transcription pathway
that prompts the expression of interferon-stimulated
genes (ISGs), which results in antiviral activity against
HCV [20]. Abnormal expression of the IL28B (IFN-l3)
gene could, in theory, enhance or reduce antiviral activity
[21]. However, ISGs (associated with a lower response to
INF-a) are strongly linked to IL28B alleles [21], so that
patients with reduced ISG expression would have lower
endogenous interferon activity but a correspondingly
better response to exogenous interferon [21,22]. Our
study was consistent with this hypothetical mechanism;
patients with the IL28B-CC genotype had higher
1013
baseline HCV viral loads than non-CC patients (lower
endogenous IFN-l3 activity), and greater HCV viral
decline in the first weeks of starting treatment than nonCC patients (providing the best response to exogenous
IFN- a).
A previous study carried out by our group revealed that
IL28B and LDLr genotypes had a synergistic effect on
SVR rates in HIV/HCV genotype 1/4 co-infected
patients [13]. The results of the present study show that
the LDLr genotype modifies the influence of the IL28B
genotype on HCV viral kinetics in response to PEGIFN/RBV treatment. This enables us to hypothesize that
the potential synergistic effect between LDLr and IL28B
genotypes could be due to enhanced HCV RNA viral
decline, leading to a higher RVR rate [13]. In our study,
we found differences of HCV RNA load reduction
between IL28B-CC /LDLr-CC and IL28B-CC /LDLr
non-CC genotypes from baseline at every time-point
analyzed, but not between weeks 1 and 2, nor between
weeks 2 and 4. This is an important issue because it
implies that the synergistic effect of the IL28B/LDLr
genotype occurs during the first phase of viral decay,
thought to be due to the clearance of free virions and the
inhibition of new viral production, rather than in the
slower second phase, the gradient of which is thought to
mirror the process of infected cell clearance.
In our study, patients carrying the IL28B-CC but not the
LDLr-CC genotype showed similar declines in HCV
viral load to the IL28B non-CC genotype at every timepoint analyzed (Fig. 2). This is significant because it could
suggest that the increased early viral decline rate
associated with IL28B-CC is only be demonstrated in
the presence of an LDLr genotype. If this was confirmed,
it would have considerable repercussions on clinical
practice, since a determination of IL28B on its own
without the LDLr genotype would have limited power
for clinical decision-making.
Our study has several limitations. Firstly, the number of
patients included was small, and did not have the statistical
power to detect differences among CC/non-CC and
IL28B non-CC patients. A powerful cohort of HIV/HCV
genotype 1 co-infected patients is needed to analyze the
synergistic effect of IL28B and LDLr genotypes. Secondly,
our study looked at the impact of LDLr and IL28B by
determining only SNPs rs14158 and rs12979860, respectively. Studies analyzing the synergistic effect of other
known LDL SNPs (rs3826810, rs2738464, rs2738465,
rs1423099, rs2738466) and IL28B (rs8099917) are needed.
A third limitation is that this study included only HIV/
HCV co-infected patients, which represents a unique
population. HIV/HCV co-infected patients, in fact, attain
SVR less frequently than HCV mono-infected individuals
and their HCV viral decline is slower [23,24]. Hence,
further studies on the predictive yield of LDLr gene
variations are needed that include HCV monoinfected
1014
AIDS
2012, Vol 26 No 8
patients. However, it is not expected that rs14158 behavior
and its synergistic effect with rs12979860 will differ in the
HCV monoinfected subset.
In conclusion, our results show a positive association
between LDLr (rs14158) and IL28B (rs12979860) on
HCV viral decline during the first week after start of
treatment with PEG-IFN/RBV in HIV-infected patients
carrying HCV genotype 1. Currently, information about
their IL28B status is being used to inform patients about
the likelihood of obtaining a response from PEG-IFN/
RBV combination therapy. Whether the additional
determination of LDLr status will be a better predictor
of response to HCV combination therapy, and whether it
should be used for making decisions about treatment in
these patients, remains to be studied.
Acknowledgements
Study concept and design: A.R.
Acquisition of data: A.R., A. Camacho, J.A.P.
Analysis and interpretation of data: A.R.J., A.R., A.
Camacho, J.A.P., K.N.
Drafting of the manuscript: A.R.J., A.R.
Critical revision of the manuscript for important
intellectual content: A.R.J., A.R., J.A.P., A. Caruz,
F.A.D., A. Camacho, R.H., J.P., R.G., I.P.C., K.N.
Statistical analysis: A.R.J., A. Camacho.
Obtained funding: J.A.P., A. Caruz, A.R.
Administrative, technical, or material support: A. Caruz,
F.A.D., R.H., K.N., A.R.J, I.P.C., J.P., R.G.
Study supervision: A.R., J.A.P.
Conflicts of interest
The work was partly supported by grants from the
Fundación Progreso y Salud, Consejerı́a de Salud de la
Junta de Andalucı́a (grants for health research projects:
refs. 0036/2010, FIS-PS09/00424, PI-0247-2010 and
PI-0208 and 0124/2008) and the Spanish Health
Ministry (ISCIII-RETIC RD06/006, and projects
PI10/0164 and PI10/01232). A.R. is the recipient of a
research extension grant from the Fundación Progreso y
Salud, Consejerı́a de Salud de la Junta de Andalucı́a
(Reference AI-0011-2010); J.A.P. is the recipient of an
extension grant from the Fundación Progreso y Salud of
the Consejerı́a de Salud de la Junta de Andalucı́a
(Reference AI-0021). K.N. is the recipient of a Sara
Borrell postdoctoral perfection grant from the Instituto
de Salud Carlos III (SCO/523/2008).
References
1. Rivero-Juarez A, Camacho A, Perez-Camacho I, Neukam K,
Caruz A, Mira JA, et al. Association between the IL28B genotype and hepatitis C viral kinetics in the early days of treatment
with pegylated interferon plus ribavirin in HIV/HCV coinfected patients with genotype 1 or 4. J Antimicrob Chemother
[Epub ahead of print].
2. Thompson AJ, Muir AJ, Sulkowski MS, Ge D, Fellay J, Shianna
KV, et al. Interleukin-28B polymorphism improves viral
kinetics and is the strongest pretreatment predictor of sustained virologic response in genotype 1 hepatitis C virus.
Gastroenterology 2010; 139:120–129.
3. Stättermayer AF, Stauber R, Hofer H, Rutter K, Beinhardt S,
Scherzer TM, et al. Impact of IL28B genotype on early and
sustained virologic response in treatment-naı̈ve patients with
chronic hepatitis C. Clin Gastroenterol Hepatol 2011; 9:344–
350.
4. Howell CD, Gorden A, Ryan KA, Thompson AJ, Ibrahim C,
Fried M, et al. Single nucleotide polymorphism upstream of
interleukin 28B associated with phase 1 and phase 2 of early
viral kinetics in patients infected with HCV genotype 1.
J Hepatol 2011. doi: 10.1016/j.jhep.2011.10.004.
5. Pineda JA, Caruz A, Rivero A, Neukan K, Salas I, Camacho A,
et al. Prediction of response to pegylated interferon plus
ribavirin by IL28B gene variation in patients coinfected with
HIV and hepatitis C virus. Clin Infect Dis 2010; 51:788–795.
6. Ge D, Fellay J, Thompson AJ, Simon JS, Shianna KV, Urban TJ,
et al. Genetic variation in IL28B predicts hepatitis C treatmentinduced viral clearance. Nature 2009; 461:399–401.
7. Ye J. Reliance of host cholesterol metabolic pathways for the
life cycle of hepatitis C virus. PLoS Pathog 2007; 3:1017–1022.
8. Ogawa K, Hishiki T, Shimizu Y, Funami K, Sugiyama K,
Miyanari Y, et al. Hepatitis C virus utilizes lipid droplet for
production of infectious virus. Proc Jpn Acad Ser B 2009;
85:217–228.
9. Dai CY, Chuang WL, Ho CK, Ou TT, Huang JF, Hsieh MY, et al.
Associations between hepatitis C viremia and low serum
triglyceride and cholesterol levels: a community-based study.
J Hepatol 2008; 49:9–16.
10. Miyazaki T, Honda A, Ikegami T, Saitoh Y, Hirayama T, Hara T,
et al. Hepatitis C virus infection causes hypolipidemia regardless of hepatic damage or nutritional state-an epidemiological
survey of a large Japanese cohort. Hepatol Res 2011; 41:530–
541.
11. Kurosaki M, Matsunaga K, Hirayama I, Tanaka T, Sato M, Yasusi
Y, et al. A predictive model of response to peginterferon
ribavirin in chronic hepatitis C using classification and regression tree analysis. Hepatol Res 2010; 40:251–260.
12. del Valle J, Mira JA, de los Santos I, López-Cortés LF, Merino D,
Rivero A, et al. Baseline serum low-density lipoprotein cholesterol levels predict sustained virological response to pegylated
interferon plus ribavirin in HIV/Hepatitis C virus-coinfected
patients. AIDS 2008; 22:923–930.
13. Pineda JA, Caruz A, Di Lello FA, Camacho A, Mesa P, Neukam
K, et al. Low-density lipoprotein receptor genotyping enhances
the predictive value of IL28B genotype in HIV/hepatitis C
virus-coinfected patients. AIDS 2011; 25:1415–1420.
14. Ghany MG, Strader DB, Thomas DL, Seeff LB. Diagnosis management and treatment of hepatitis C: an update. AASLD
Practice Guidelines. Hepatology 2009; 49:1335–1374.
15. Burlone ME, Budkowska A. Hepatitis C virus cell entry: role of
lipoproteins and cellular receptors. J Gen Virol 2009; 90:1055–
1070.
16. von Hahn T, Rice CM. Hepatitis C virus entry. J Biol Chem
2008; 283:3689–3693.
17. Dubuisson J, Helle F, Cocquerel L. Early steps of the hepatitis C
virus life cycle. Cell Microbiol 2008; 10:821–827.
18. Pietschmann T. Virology: final entry key for hepatitis C. Nature
2009; 457:797–798.
19. Hsu CS, Liu CH, Liu CJ, Chen CL, Lai MY, Chen PJ, et al. Factors
affecting early viral load decline of Asian chronic hepatitis C
patients receiving pegylated interferon plus ribavirin therapy.
Antivir Ther 2009; 14:45–54.
20. Zhang L, Jilg N, Shao R-X, Lin W, Fusco DN, Zhao H, et al.
IL28B inhibits hepatitis C virus replication through the JAKSTAT pathway. J Hepatol 2011; 55:1–10.
21. Urban TJ, Thompson AJ, Bradrick SS, Fellay J, Schuppan D,
Cronin KD, et al. IL28B genotype is associated with differential
expression of intrahepatic interferon-stimulated genes in
patients with chronic Hepatitis C. Hepatology 2010; 52:1888–
1896.
22. Asselah T, Bieche I, Narguet S, Sabbagh A, Laurendeau I, Ripault
MP, et al. Liver gene expression signature to predict response
to pegylated interferon plus ribavirin combination therapy in
patients with chronic hepatitis C. Gut 2008; 57:516–524.
1015
23. Soriano V, Vispo E, Labarga P, Medrano J, Barreiro P. Viral
hepatitis and HIV co-infection. Antiviral Res 2010; 85:303–
315.
24. Tural C, Galeras JA, Planas R, Coll S, Sirera G, Giménez D, et al.
Differences in virological response to pegylated interferon plus
ribavirin between hepatitis C virus (HCV)-monoinfected
patients and HCV-HIV-coinfected patients. Antivir Ther
2008; 13:1047–1055.
The IL28B effect on HCV kinetics of among HIV patients after the
subtype
Running head: IL28B impact on HCV-1 subtypes
Authors:
Antonio
CAMACHO,1
RIVERO-JUAREZ,1
CARUZ,3
Antonio
MARTINEZ-DUEÑAS,
1
Luis
Almudena
LOPEZ-CORTES,2
Angela
TORRES-CORNEJO,2
Loreto
F.
Rosa RUIZ-VALDERAS,2 Julian TORRE-CISNEROS,1
Alicia GUTIERREZ-VALENCIA,2 Antonio RIVERO.1*
Affiliations:
1. Unidad de Enfermedades Infecciosas. Instituto Maimonides de Investigación
Biomédica de Córdoba (IMIBIC). Hospital Universitario Reina Sofia. Cordoba,
Spain.
2. Unidad Clínica de Enfermedades Infecciosas, Microbiología y Medicina
Preventiva. Instituto de Biomedicina de Sevilla (IBiS), Hospital Universitario
Virgen del Rocío/CSIC/Universidad de Sevilla. Spain.
3. Unidad de Inmunogenética. Faculty of Sciences. Universidad de Jaén. Spain.
Total word count: 2,147
*
Corresponding author:
Antonio Rivero.
Address: Avd. Menendez Pidal s/n. 14004. Cordoba. Spain.
Phone: 0034-957012421. Fax: 0034-957011885.
E-mail:[email protected]
Declaration of funding interests
The work was partly supported by grants from the Fundación Progreso y Salud,
Consejería de Salud de la Junta de Andalucía (grants for health research projects: refs.
0036-2010, 0157-2011, 0430-2012). A.R. was the recipient of a research extension
grant from the Fundación Progreso y Salud, Consejería de Salud de la Junta de
Andalucía (refs. AI-0021).
The IL28B effect on HCV kinetics of among HIV patients after the
subtype
Introduction
Human immunodeficiency virus (HIV) and Hepatitis C virus (HCV) co-infection is a
worldwide health problem [1]. Until recently, the standard of care for HCV genotype 1
treatment in HIV/HCV patients was a combination of pegylated-interferon (Peg-IFN)
plus ribavirin (Peg-IFN/RBV). This combination leads to a sustained virological
response (SVR) rate of 14–38% [2-5]. This rate is considerably lower than that obtained
in HCV monoinfected populations [6]. Due to this, and to the more rapid progression to
HCV liver disease and HIV infection [7], a more effective HCV-genotype 1 treatment is
a priority among HIV/HCV co-infected patients. In this respect, the incorporation of a
new family of drugs acting directly on the HCV has caused the SVR rate to soar in this
population [8, 9]. However, there are several limitations to the use of these drugs, which
could hinder its application in this subset of patients. These limitations include drugdrug interactions between HCV and antiretroviral drugs, a higher rate of adverse events,
higher costs and limited experience with the use of the drugs [10]. On the other hand,
the results of clinical trials performed with HCV-1 monoinfected patients have shown
that there are some patients who do not benefit, in terms of response, from the addition
of an HCV protease inhibitor to Peg-IFN/RBV [11, 12]. For these reasons, a key aspect,
particularly among HIV/HCV co-infected patients, is the selection of the most
appropriate treatment regimen, based on cost, safety and, mainly, prediction of
response.
Several factors have been identified as predictive of treatment response to the PegIFN/RBV combination in HIV/HCV co-infected patients [13]. In recent years, the host’s
genetic factors have played an important role in this [14, 15]. The variations of the
IL28B genotype is considered to be the most important baseline factor for treatment
response among HIV/HCV co-infected patients, so that patients with the IL28B-CC
genotype (SNP rs12979860) achieved SVR significantly more frequently than those
bearing the unfavorable genotypes (CT or TT) [15]. This improved SVR rate is due to
the higher HCV viral decline during the first weeks of starting treatment with PegIFN/RBV [16]. Even though the precise action mechanism of the IL28B genotype has
not been clarified, it has been reported that it might be related to endogenous IFN
production [17]. However, the effect of IL28B genotype on treatment response could be
influenced by several factors [18, 19].
Among patients infected by genotype 1, it appears that those with the HCV-1b genotype
have higher response rates than those infected by the HCV-1a genotype [20]. The
reason for this is unknown, although it could be related to the differences of IFN
sensitivity between the two subtypes [21]. As a result of this, it is thought that the
possible differences in IFN sensitivity could be influenced by the IL28B genotype.
Thus, the aim of our study is to consider the influence of IL28B on treatment response
of HIV/HCV co-infected patients infected with the HCV-1a or HCV-1b genotypes, as
reflected in HCV viral decline during the first weeks of treatment.
Methods
Patients included
Caucasian HIV-infected patients with chronic hepatitis C and naïve to HCV PegIFN/RBV combination therapy were included. Patients who were positive for the
hepatitis B surface antigen (HBsAg) were excluded. Variables related to the patient
were collected (age [years], body mass index [Kg/m2] and gender), as well as clinical
variables related to the liver (fasting LDL cholesterol [mg/dL], ALT [IU/L] and liver
fibrosis staging); HIV characteristics (use of HAART, HIV viral load [IU/mL], AIDS
clinical condition, baseline CD4 cell count [cells/mL] and risky practices for HIV
infection); and HCV variables (HCV genotype 1 subtype, HCV viral load [IU/mL] and
IL28B genotype). Fibrosis stage was determined by liver biopsy, liver fibrosis staging
on the basis of the METAVIR fibrosis score. Liver transient elastography (FibroScan®,
Echosens, Paris) was used to measure the liver stiffness values of those patients who
had not undergone a liver biopsy. In such cases, a liver stiffness value ≥14.6 kPa was
defined as indicating liver cirrhosis [22].
Treatment Regimens
All individuals were treated with Peg-IFN-alpha-2a, at doses of 180 µg per week, in
combination with a weight-adjusted dose of oral ribavirin (1000 mg/day for <75 kg and
1200 mg/day for ≥75 kg, respectively) for 48 or 72 weeks, following international
guidelines [23].
Virological evaluation and response
Plasma HCV RNA loads were measured at baseline and at weeks 1, 2 and 4 using a
quantitative PCR assay (CobasTaqMan, Roche Diagnostic Systems Inc., Pleasanton,
CA, USA), with a detection limit of 15 IU/mL. The HCV genotype was determined
using a hybridization assay (INNO-LiPa HCV, Bayer Corp., Tarrytown, NY, USA) and
HCV subtypes were defined as 1a or 1b. Rapid virological response (RVR) was defined
as an undetectable viral load at week 4 after starting treatment.
Single Nucleotide Polymorphism (SNP) genotyping
DNA was extracted using the automated MagNA Pure DNA extraction method (Roche
Diagnostics Corporation. Indianapolis, IN 46250, USA). SNP rs129679860, located 3
kilobases upstream of the IL28B, and in strong linkage disequilibrium with a nonsynonymous coding variant in the IL28B gene (213A>G, K70R; rs81031142), was
genotyped. Genotyping was carried out using a custom TAQMAN assay (Applied
Biosystems, Foster City, California, USA) on DNA isolated from whole blood samples,
using a Stratagene MX3005 thermocycler with MXpro software (Stratagene, La Jolla,
California, USA), according to manufacturer’s instructions. The researchers responsible
for genotyping were blinded to other patient data. The IL28B genotype was defined as
CC or non-CC (TT/CT).
Statistical Analysis
Continuous variables were expressed as mean ± standard deviation and were analyzed
by the Student’s t test, Mann-Whitney U-test or Kruskal-Wallis test. Categorical
variables were expressed as number of cases (percentage). Frequencies were compared
using the χ2 test or Fisher’s exact test. Significance was defined as a p value of less than
0.05. Plasma HCV-RNA kinetic throughout the first 4 weeks of therapy was analyzed
according to HCV-1 subtype (1a versus 1b). We also analyzed the effect of the IL28B
genotype on HCV viral decline in HCV-1a and HCV-1b genotype patients (CC versus
non-CC). Three linear regression models were performed to identify independent
predictors of HCV viral decline during the first weeks of treatment. The first model
developed included the total population, and HCV-1 subtype (1a or 1b) was entered into
the model as a variable; the second model developed included only patients infected by
the HCV-1a genotype; and the third model used patients infected by the HCV-1b
genotype. The coefficient (B) of the models was shown as an adjusted coefficient. The
Durbin-Watson statistic was used to detect the presence of autocorrelation in variables
included in the models. The analysis was performed using the SPSS statistical software
package, version 18.0 (IBM Corporation, Somers, NY, USA).
Ethical aspects
The study was designed and performed according to the Helsinki Declaration and
approved by the ethics committee of the Reina Sofía University Hospital, Cordoba,
Spain.
Results
Patients included
Two hundred and six patients in follow-up at two reference hospitals in Spain were
included in the study. Of these, 113 (54.8%) and 93 (45.2%) were infected with the
HCV-1a and 1b genotypes, respectively. The baseline characteristics of population are
shown in Table 1. Thirty-two (15.5%) patients achieved RVR.
Viral decline according to HCV-1 subtypes
Patients infected with the HCV-1b genotype had higher, although not statistically
significant, HCV viral declines than those infected by HCV-1a, at week 1 (1b: 0.77 ±
0.38; 1a: 0.51 ± 0.41, p = 0.14), week 2 (1b: 1.12 ± 0.44; 1a: 0.96 ± 0.58, p = 0.358) and
week 4 (1b: 1.89 ± 0.46; 1a: 1.66 ± 0.4, p = 0.279) (Figure 1).
The linear regression models of HCV viral decline at the different time points analyzed
identified only baseline HCV viral load and IL28B genotype as independent predictive
factors (Table 2). This analysis did not identify the HCV-1b genotype predictive of
higher HCV viral decline compared to the HCV-1a genotype.
Impact of the IL28B genotype by the two HCV-1 subtypes
The IL28B-CC genotype had a weak impact on HCV viral decline among patients
infected with the HCV-1a genotype, at week 1 (CC: 0.46 ± 0.34; non-CC: 0.51 ± 0.38, p
= 0.804), week 2 (CC: 1.04 ± 0.58; non-CC: 0.88 ± 0.51, p = 0.52) and week 4 (CC:
1.73 ± 0.35; non-CC: 1.58 ± 0.41, p = 0.63) (Figure 2A). However, among patients
infected with HCV-1b, those with IL28B-CC showed greater reductions in HCV viral
load than those with the IL28B non-CC genotype, at weeks 1 (CC: 1.53 ± 0.33; nonCC: 0.27 ± 0.24, p < 0.001), 2 (CC: 1.81 ± 0.39; non-CC: 0.74 ± 0.39, p = 0.002) and 4
(CC: 2.97 ± 0.53; non-CC: 1.2 ± 0.61, p < 0.001) (Figure 2B). Furthermore, when HCV
viral decline among patients carrying the IL28B-CC genotype was compared on the
basis of HCV-1 subtype, those infected with HCV-1b showed greater reductions than
those with the HCV-1a genotype, at every time point analyzed (week 1: p = 0.003; week
2: p = 0.026; week 4: p < 0.001).
The two linear regression models of the different subsets of patients (HCV-1a and
HCV-1b genotypes) identified the IL28B genotype as an independent predictor of HCV
viral decline only among patients infected with the HCV-1b genotype, at every time
point analyzed (Table 2).
RVR rate
Figure 3 shows RVR rates. HCV-1a and HCV-1b subtypes had similar rates of RVR
and there were no differences of RVR rate found among patients infected by HCV-1a,
on the basis of IL28B genotype. However, for HCV-1b, patients bearing IL28B-CC had
higher RVR rates than IL28B non-CC patients.
Discussion
In our study, we found no differences of HCV viral decline during the first weeks of
treatment or of RVR rate between HCV genotypes 1a and 1b in HIV co-infected
patients naïve to Peg-IFN/RBV treatment. At the same time, the positive effect on viral
clearance that is associated with IL28B-CC was observed in HCV-1b infected patients,
but not those with the HCV-1a subtype. The higher response rate to treatment of HCV1b over HCV-1a has been reported in several studies [20, 24], although the reason for it
has not been clearly explained. On the basis of our results, the better rate of response
associated with the HCV-1b genotype could be due to the IL28B-CC genotype exerting
a stronger effect on HCV viral clearance than it does among HCV-1a patients. The
reason for this is unknown. It has been reported that mutations in HCV proteins (both
structural and nonstructural) have a modulatory impact on treatment response [25, 26].
The mechanism could be associated with the sensitivity of the HCV virus to IFN [27,
28]. So, patients bearing HCV strains with mutations at core amino acid 70R showed
higher SVR rates than those with mutations at 70Q [29, 30]. In the same way, various
mutations of the HCV NS5A protein are able to enhance or decrease HCV sensitivity to
IFN, so affecting the response to treatment [27]. The HCV-1b genotype tends to have
more “favourable” mutations associated with IFN sensitivity, so that the better PegIFN-alpha-2a -based response to therapy among HCV-1b patients could be the result of
this mechanism [21]. The different variations of the IL28B genotype have been related
to higher (IL28B non-CC genotype) or lower (IL28B-CC genotype) endogenous IFNlambda activity, so that it would be expected for lower endogenous IFN-lambda activity
to trigger a higher antiviral response when exogenous Peg-IFN-alpha-2a was added
[31]. For this reason, patients with a more IFN-sensitive virus and the IL28B-CC
genotype should experience higher viral decline when exogenous Peg-IFN-alpha-2a is
added. Other studies have reported a similar association between HCV viral protein
mutations and the IL28B genotype [32-34]. However, we did not carry out assays to
investigate IFN sensitivity mutations of the HCV genome in our patients. It would be
extremely useful to clarify whether the different impact of HCV-1 subtypes of the
IL28B genotype in HIV co-infected patients correlates with other HCV amino acid
mutations.
We currently have direct-acting antiviral drugs available for HCV which increase the
SVR of both HCV-1 infected and HIV co-infected patients [8, 9]; although even as the
SVR increases, so does the rate of adverse events; furthermore, even though the
therapeutic arsenal continues to expand, Peg-IFN will remain a part of HCV treatment
in the coming years. In our study, 33.3% of patients infected with the HCV-1b genotype
and carrying ILB28-CC achieved RVR, the best predictor of SVR. This suggests that
this subset of patients could be considered as potential responders to Peg-IFN-alpha2a/RBV therapy. This observation could help clinicians decide on the proper treatment
regimen for each patient, chiefly on the basis of its clinical benefit.
In conclusion, in our study, the IL28B-CC genotype had a positive effect on HCV viral
clearance during the first weeks of treatment with Peg-IFN-alpha-2a/RBV and on RVR
rates in HCV-1b genotype HIV co-infected patients, but not those with HCV-1a. Both
clinical and experimental studies are needed to clarify the possible association between
IL28B and the HCV-1b subtype.
Acknowledgements
Study concept and design: A. R-J, A.R.
Acquisition of data: A. R-J, A. Camacho, A. T-C, L. M-D, R. R-V, A. G-V.
Analysis and interpretation of data: A. R-J, LF L-C, A. Camacho, A. R.
Critical revision of the manuscript for important intellectual content: All authors
Statistical analysis: A. R-J, A Camacho.
Obtained funding: A.R, LF L-C.
Administrative technical or material support: A. R-J, A Caruz, A. T-C, L. M-D, R. R-V,
A. G-V.
Study supervision: A. R, LF L-C.
References
[1] Taylor LE, Swan T, Mayer KH. HIV coinfection with hepatitis C virus: evolving
epidemiology and treatment paradigms. Clin Infect Dis. 2012; 55 (Suppl 1): S33-42
[2] Carrat F, Bani-Sadr F, Pol S, Rosenthal E, Lunel-Fabiani F, Benzekri A et al.
Pegylated interferon alfa-2b vs standard interferon alfa-2b, plus ribavirin, for chronic
hepatitis C in HIV-infected patients: a randomized controlled trial. JAMA 2004; 292:
2839-48
[3] Torriani FJ, Rodriguez-Torres M, Rockstroh JK, Lissen E, Gonzalez-García J,
LazzarinA et al. Peginterferon Alfa-2a plus ribavirin for chronic hepatitis C virus
infection in HIV-infected patients. N Engl J Med 2004; 351: 438-50
[4] Chung RT, Andersen J, Volberding P, Robbins GK, Liu T, Sherman KE et al.
Peginterferon Alfa-2a plus ribavirin versus interferon alfa-2a plus ribavirin for chronic
hepatitis C in HIV-coinfected persons. N Engl J Med 2004; 351: 451-9
[5] Laguno M, Murillas J, Blanco JL, Martínez E, Miquel R, Sánchez-Tapias JM et al.
Peginterferon alfa-2b plus ribavirin compared with interferon alfa-2b plus ribavirin for
treatment of HIV/HCV co-infected patients. AIDS 2004; 18: 27-36.
[6] Ghany MG, Strader DB, Thomas DL, Seeff LB; American Association for the Study
of Liver Diseases. Diagnosis, management, and treatment of hepatitis C: an update.
Hepatology 2009; 49: 1335-74
[7] Hernandez MD, Sherman KE. HIV/hepatitis C coinfection natural history and
disease progression. Curr Opin HIV AIDS 2011; 6: 478-82
[8] Sulkowski MS, Pol S, Cooper C, Fainboim H, Slim J, Rivero A et al. Boceprevir +
Pegylated Interferon + Ribavirin for the Treatment of HCV/HIV-co-infected Patients:
End of Treatment (Week-48) Interim Results. 19th Conference on Retroviruses and
Opportunistic Infections (CROI 2012). Seattle, WA. March 5-8, 2012. Abstract 47
[9] Sulkowski MS, Sherman KE, Soriano V, Rockstroh J, Dieterich DT, Girard P et al.
Telaprevir in combination with peginterferon alfa-2a/ribavirin in HIV/HCV co-infected
patients: SVR24 final study results. 63rd AASLD, 2012, Boston. Abstract 54
[10] Sulkowski MS. Hepatitis C virus-human immunodeficiency virus coinfection.
Liver Int. 2012; 32 (Suppl 1):129-34
[11] Jacobson IM, McHutchison JG, Dusheiko G, Di Bisceglie AM, Reddy KR, Bzowej
NH et al. Telaprevir for previously untreated chronic hepatitis C virus infection. N Engl
J Med 2011; 364: 2405-16.
[12] Poordad F, McCone J Jr, Bacon BR, Bruno S, Manns MP, Sulkowski MS et al.
Boceprevir for untreated chronic HCV genotype 1 infection. N Engl J Med 2011; 364:
1195-206
[13] Vachon ML, Dieterich DT. The HIV/HCV-coinfected patient and new treatment
options. Clin Liver Dis 2011; 15: 585-96
[14] Pineda JA, Caruz A, Di Lello FA, Camacho A, Mesa P, Neukam K et al. Lowdensity lipoprotein receptor genotyping enhances the predictive value of IL28B
genotype in HIV/hepatitis C virus-coinfected patients. AIDS 2011; 25: 1415-20
[15] Pineda JA, Caruz A, Rivero A, Neukam K, Salas I, Camacho A et al. Prediction of
response to pegylated interferon plus ribavirin by IL28B gene variation in patients
coinfected with HIV and hepatitis C virus. Clin Infect Dis 2010; 51: 788-95
[16] Rivero-Juarez A, Camacho Espejo A, Perez-Camacho I, Neukam K, Caruz A, Mira
JA et al. Association between the IL28B genotype and hepatitis C viral kinetics in the
early days of treatment with pegylated interferon plus ribavirin in HIV/HCV co-infected
patients with genotype 1 or 4. J Antimicrob Chemother 2012; 67: 202-5
[17] Urban TJ, Thompson AJ, Bradrick SS, Fellay J, Schuppan D, Cronin KD et al.
IL28B genotype is associated with differential expression of intrahepatic interferonstimulated genes in patients with chronic hepatitis C. Hepatology 2010; 52: 1888-96
[18] Rivero-Juarez A, Camacho A, Caruz A, Neukam K, Gonzalez R, Di Lello FA et al.
LDLr genotype modifies the impact of IL28B on HCV viral kinetics after the first
weeks of treatment with PEG-IFN/RBV in HIV/HCV patients. AIDS 2012; 26: 1009-15
[19] Naggie S, Osinusi A, Katsounas A, Lempicki R, Herrmann E, Thompson AJ et al.
Dysregulation of innate immunity in hepatitis C virus genotype 1 IL28B-unfavorable
genotype patients: impaired viral kinetics and therapeutic response. Hepatology 2012;
56: 444-54
[20] Legrand-Abravanel F, Colson P, Leguillou-Guillemette H, Alric L, Ravaux I,
Lunel-Fabiani F et al. Influence of the HCV subtype on the virological response to
pegylated interferon and ribavirin therapy. J Med Virol 2009; 81: 2029-35
[21] Donlin MJ, Cannon NA, Yao E, Li J, Wahed A, Taylor MW et al. Pretreatment
sequence diversity differences in the full-length hepatitis C virus open reading frame
correlate with early response to therapy. J Virol 2007; 81: 8211-24
[22] Vergara S, Macías J, Rivero A, Gutiérrez-Valencia A, González-Serrano M,
Merino D et al. The use of transient elastometry for assessing liver fibrosis in patients
with HIV and hepatitis C virus coinfection. Clin Infect Dis 2007; 45: 969-74
[23] Ghany MG, Strader DB, Thomas DL, Seeff LB. Diagnosis, Management and
Treatment of Hepatitis C: An update. AASLD PracticeGuidelines. Hepatology 2009;
49: 1335–1374
[24] Berg T, von Wagner M, Nasser S, Sarrazin C, Heintges T, GerlachT et al.
Extended treatment duration for hepatitis C virus type 1: comparing 48 versus 72 weeks
of peginterferon-alfa-2a plus ribavirin. Gastroenterology 2006; 130: 1086-97
[25] Kurosaki M, Tanaka Y, Nishida N, Sakamoto N, Enomoto N, Honda M et al. Pretreatment prediction of response to pegylated-interferon plus ribavirin for chronic
hepatitis C using genetic polymorphism in IL28B and viral factors. J Hepatol 2011; 54:
439-48
[26] Enomoto N, Maekawa S. HCV genetic elements determining the early response to
peginterferon and ribavirin therapy. Intervirology 2010; 53: 66-9
[27] Enomoto N, Sakuma I, Asahina Y, Kurosaki M, Murakami T, Yamamoto C et al:
Mutations in the nonstructural protein 5A gene and response to interferon in patients
with chronic hepatitis C virus 1b infection. N Engl J Med 1996; 334: 77–81
[28] Hiraga N, Abe H, Imamura M, Tsuge M, Takahashi S, Hayes CN et al. Impact of
viral amino acid substitutions and host interleukin-28b polymorphism on replication and
susceptibility to interferon of hepatitis C virus. Hepatology 2011; 54: 764-71
[29] Alestig E, Arnholm B, Eilard A, Lagging M, Nilsson S, Norkrans G et al. Core
mutations, IL28B polymorphisms and response to peginterferon/ribavirin treatment in
Swedish patients with hepatitis C virus genotype 1 infection. BMC Infect Dis 2011; 11:
124
[30] Kurbanov F, Tanaka Y, Matsuura K, Sugauchi F, Elkady A, Khan A et al. Positive
selection of core 70Q variant genotype 1b hepatitis C virus strains induced by pegylated
interferon and ribavirin. J InfectDis 2010; 201: 1663-71
[31] Urban T, Charlton MR, Goldstein DB. Introduction to the genetics and biology of
interleukin-28B. Hepatology 2012; 56: 361-6
[32] Maekawa S, Sakamoto M, Miura M, Kadokura M, Sueki R, Komase K et al.
Comprehensive analysis for viral elements and interleukin-28B polymorphisms in
response to pegylated interferon plus ribavirin therapy in hepatitis C virus 1B infection.
Hepatology 2012; 56: 1611-21
[33] Hayashi K, Katano Y, Honda T, Ishigami M, Itoh A, Hirooka Y et al. Association
of interleukin 28B and mutations in the core and NS5A region of hepatitis C virus with
response to peg interferon and ribavirin therapy. Liver Int 2011; 31: 1359-65
[34] Hayes CN, Kobayashi M, Akuta N, Suzuki F, Kumada H, Abe H et al. HCV
substitutions and IL28B polymorphisms on outcome of peg-interferon plus ribavirin
combination therapy. Gut 2011; 60: 261-7
Table 1 Baseline characteristics of population.
Characteristics
Total
HCV-1a
HCV-1b
206
113
93
Male. No. (%)
177 (85.9)
93 (82.3)
80 (86.02)
0.509
Age (Years). Mean ± SD
42.1 ± 5.6
41.6 ±5.2
42.6 ± 6.2
0.223
BMI (Kg/m2). Mean ± SD
23.9 ± 3.97
24.3 ± 3.6
23.6 ± 4.3
0.258
AIDS clinical condition. No. (%)†
55 (26.7)
22 (19.4)
23 (24.7)
0.355
IDU. No. (%)
181 (87.8)
102 (90.2)
88 (94.6)
0.247
Undetectable HIV viral load. No. (%)ǂ
181 (87.8)
97 (85.8)
84 (90.3)
0.34
Use of HAART. No. (%)
194 (94.1)
107 (94.6)
86 (92.4)
0.482
CD4 cells count (cells/mL). Mean ± SD
562 ± 271
560 ± 295
548 ± 236
0.744
N
p*
Baseline HCV viral load (log10 IU/mL). Mean ±
6.2 ± 0.79
6.2 ± 0.79
6.18 ± 0.79
0.665
70 (33.9)
41 (36.3)
29 (31.1)
0.419
86.2 ± 29.4
84.3 ± 28.6
87.7 ± 31.7
0.445
80 ± 57
82.1 ± 63.2
77.9 ± 51.2
0.613
84 (40.7)
45 (39.8)
39 (41.9)
0.723
SD
Liver cirrhosis stage. No. (%)
Fasting LDL cholesterol (mg/dL). Mean ± SD
ALT (IU/L). Mean ± SD
IL28B-CC genotype. N (%)
Legend: Hepatitis C virus genotype 1a (HCV-1a); hepatitis C virus genotype 1b (HCV-1b); number of patients (No.); standard deviation (SD);
Body Mass Index (BMI): acquired immunodeficiency syndrome (AIDS): injecting drug user (IDU); human immunodeficiency virus (HIV);
highly active antiretroviral treatment (HAART); low-density-lipoprotein (LDL); alanine transaminase (ALT); interleukin 28B (IL28B).
*p value compared value of HCV-1a and HCV-1b genotypes.
†
Classified on the basis of Center for Disease Control and Prevention (CDC) recommendations (Revised surveillance case definitions for HIV
infection among adults, adolescents, and children aged <18 years and for HIV infection and AIDS among children aged 18 months to <13 yearsUnited States, 2008. MMWR 2008; 57 (No RR-10): 1-14).
ǂ
HIV viral load was measured by PCR (CobasTaqMan, Roche Diagnostic Systems Inc., Pleasanton, CA, USA), detection limit set at 20 IU/mL.
Table 2 Linear regression models for HCV viral decline at weeks 1, 2 and 4 after starting treatment.
Week 1*
Condition
Total population
Genotype 1a
Genotype 1b
B
p
B
p
B
p
BMI
-0.021
0.851
-0.131
0.454
0.187
0.252
Baseline HCV viral load
-0.253
0.025
-0.206
0.254
-0.106
0.545
Liver fibrosis F3-F4
-0.122
0.264
-0.183
0.269
-0.095
0.577
LDL cholesterol
0.116
0.276
0.068
0.691
-0.077
0.663
IL28B Non-CC
-0.287
0.01
-0.025
0.889
-0.62
0.001
HCV genotype 1b
0.179
0.106
Week 2†
Condition
BMI
Total population
Genotype 1a
Genotype 1b
B
p
B
p
B
p
-0.038
0.665
-0.15
0.232
0.14
0.273
-0.133
0.134
-0.084
0.505
-0.166
0.228
-0.142
0.114
-0.236
0.062
-0.145
0.287
LDL cholesterol
0.036
0.685
-0.014
0.98
-0.16
0.397
IL28B Non-CC
-0.223
0.012
0.074
0.553
-0.52 <0.001
HCV genotype 1b
0.006
0.942
Week 4‡
Condition
Total population
Genotype 1a
Genotype 1b
B
p
B
p
B
p
BMI
-0.067
0.415
-0.138
0.251
0.092
0.395
-0.098
0.225
-0.078
0.516
-0.04
0.702
0.011
0.892
0.025
0.836
-0.058
0.579
LDL cholesterol
0.116
0.164
0.111
0.356
-0.043
0.710
IL28B No-CC
-0.319
<0.001
-0.033
0.786
-0.698 <0.001
HCV genotype 1b
0.022
0.79
Legend: coefficient (B), body mass index (BMI), hepatitis C virus (HCV), low-density-lipoprotein (LDL), interleukin 28B (IL28B). Coefficients
show the difference of HCV viral decline of a condition, with respect to its opposite, at different time points. BMI, HCV viral decline per unit
increase of BMI; Baseline viral load, HCV viral decline per unit increase (log/IU) of HCV viral load; Liver fibrosis F3-F4, HCV viral decline
compared with absence of F3-F4 liver fibrosis; LDL cholesterol, HCV viral decline per unit increase in LDL cholesterol; IL28B non-CC, HCV
viral decline compared with IL28B-CC genotype; HCV genotype 1b, HCV viral decline compared with HCV genotype 1a.
*Week 1 model adjusted R2 values for Total Population (R2= 0.235), Genotype 1a (R2= 0.058) and Genotype 1b (R2 = 0.432) models.
†
Week 1 model adjusted R2 values for Total Population (R2= 0.087), Genotype 1a (R2= 0.081) and Genotype 1b (R2 = 0.270) models.
‡
Week 1 model adjusted R2 values for Total Population (R2= 0.145), Genotype 1a (R2= 0.033) and Genotype 1b (R2 = 0.468) models.
Figure 1 HCV viral decline (log10 IU/mL) of patients infected with HCV-1a and HCV-1b genotypes at weeks 1, 2 and 4 after starting treatment
with Peg-IFN/RBV.
Figure 2 HCV viral decline (log10 IU/mL) of patients infected with the HCV-1a (A) and HCV-1b (B) genotypes at weeks 1, 2 and 4 after starting
treatment with Peg-IFN/RBV, by IL28B genotype (CC versus Non-CC).
Figure 3 RVR rates according to HCV-1 subtype and IL28B genotype.
Differences in HCV Viral Decline between Low and
Standard-Dose Pegylated-Interferon-Alpha-2a with
Ribavirin in HIV/HCV Genotype 3 Patients
Antonio Rivero-Juárez1,2, Luis F. Lopez-Cortes3, Angela Camacho1,2, Almudena Torres-Cornejo3,
Juan A. Pineda4, Manuel Marquez-Solero5, Antonio Caruz6, Rosa Ruiz-Valderas3, Julian TorreCisneros1,2, Alicia Gutierrez-Valencia3, Antonio Rivero1,2*
1 Unit of Infectious Diseases, Hospital Universitario Reina Sofia, Cordoba, Spain, 2 Maimonides Institute for Biomedical Research, Cordoba, Spain, 3 Enfermedades
Infecciosas, Microbiologı́a y Medicina Preventiva, Instituto de Biomedicina de Sevilla, Hospital Universitario Virgen del Rocı́o/Consejo Superior de Investigaciones
Cientı́ficas/Universidad de Sevilla, Seville, Spain, 4 Unit of Infectious Diseases, Hospital Universitario de Valme, Seville, Spain, 5 Unit of Infectious Diseases, Hospital
Universitario Virgen de la Victoria, Malaga, Spain, 6 Immunogenetics Unit, Faculty of Sciences, Universidad de Jaén, Jaen, Spain
Abstract
Background: The aim of the study was to analyze the different impact of standard and low-dose Peg-IFN-a2a/RBV therapies
on HCV viral decline in HIV/HCV genotype 3 co-infected patients during the first weeks of treatment.
Methods: Plasma HCV viral decline was analyzed between baseline and weeks 1, 2 and 4 in two groups of treatment-naı̈ve
HCV genotype 3 patients with HIV co-infection. The Standard Dose Group (SDG) included patients who received Peg-IFN at
180 mg/per week with a weight-adjusted dose of ribavirin; Low-Dose Group (LDG) patients received Peg-IFN at 135 mg/per
week with 800 mg/day ribavirin. The effect of IL28B genotype on HCV viral decline was evaluated in both groups. HCV viral
decline was analyzed using a multivariate linear regression model.
Results: One hundred and six patients were included: 48 patients in the SDG and 58 in the LDG. HCV viral decline for
patients in the LDG was less than for those in the SDG (week 1:1.7260.74 log10 IU/mL versus 1.7860.67 log10 IU/mL,
p = 0.827; week 2:2.360.89 log10 IU/mL versus 3.0161.02 log10 IU/mL, p = 0.013; week 4:3.5261.2 log10 IU/mL versus
4.0961.1 log10 IU/mL, p = 0.005). The linear regression model identified the Peg-IFN/RBV dose as an independent factor for
HCV viral decline at week 4.
Conclusions: Our results showed that HCV viral decline was less for patients in the low-dose group compared to those
receiving the standard dose. Until a randomized clinical trial is conducted, clinicians should be cautious about using lower
doses of Peg-IFN/RBV in HIV/HCV genotype 3 co-infected patients.
Citation: Rivero-Juárez A, Lopez-Cortes LF, Camacho A, Torres-Cornejo A, Pineda JA, et al. (2012) Differences in HCV Viral Decline between Low and StandardDose Pegylated-Interferon-Alpha-2a with Ribavirin in HIV/HCV Genotype 3 Patients. PLoS ONE 7(11): e48959. doi:10.1371/journal.pone.0048959
Editor: Wenzhe Ho, Temple University School of Medicine, United States of America
Received August 16, 2012; Accepted October 2, 2012; Published November 8, 2012
Copyright: ß 2012 Rivero-Juárez et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits
unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Funding: This work was partly supported by grants from the Fundación Progreso y Salud, Consejerı́a de Salud de la Junta de Andalucı́a (grants for health
research projects: refs. 0036/2010, PI-0247-2010 and PI-0208 and 0124/2008) and the Spanish Health Ministry (ISCIII-RETIC RD06/006, and projects PI10/0164 and
PI10/01232). AR is the recipient of a research extension grant from the Fundación Progreso y Salud, Consejerı́a de Salud de la Junta de Andalucı́a (Reference AI0011-2010); JAP is the recipient of extension grant from the Instituto de Salud Carlos III (grant number Programa-I3SNS). The funders had no role in study design,
data collection and analysis, decision to publish, or preparation of the manuscript.
Competing Interests: AR has received consulting fees from Bristol-Myers Squibb, Abbott, Gilead, Roche and Boehringer Ingelheim. JAP has received consulting
fees from GlaxoSmithKline, Bristol-Myers Squibb, Abbott, Gilead, Merck Sharp & Dohme, Janssen-Cilag and Boehringer Ingelheim. LFLC has received funds for
speaking at symposia organized on behalf of Abbott Laboratories, Bristol-Myers Squibb, GlaxoSmithkline, Gilead Sciences, MSD, Janssen-Cilag S. A., and Viiv
Healthcare. They have received research support from GlaxoSmithKline, Roche, Bristol-Myers Squibb, Schering-Plough, Abbott and Boehringer Ingelheim, and
lecture fees from GlaxoSmithKline, Roche, Abbott, Bristol-Myers Squibb, Boehringer Ingelheim and Schering-Plough. The remaining authors have no conflicts of
interest to declare. This does not alter the authors’ adherence to all PLOS ONE policies on sharing data and materials.
* E-mail: [email protected]
treatment response rate for genotype 3 HCV patients is due the
higher rate of HCV viral clearance in the first weeks of therapy
[3]. On the other hand, it has also been observed that HCV
genotype 3 patients progress more rapidly to advanced stages of
liver fibrosis and hepatic steatosis and are at a significantly higher
risk of developing hepatocellular carcinoma [4–6]. For these
reasons, patients infected with HCV genotype 3 constitute a
population which requires the early implementation of treatment.
Introduction
The best determinant of response to hepatitis C virus (HCV)
treatment using pegylated-interferon (Peg-IFN) in combination
with ribavirin (Peg-IFN/RBV) is the HCV genotype itself. Rates of
sustained virological response (SVR) in genotypes 1 or 4 HCV
patients co-infected with HIV vary between 17 and 46% in
different studies, while for genotype 3 HCV/HIV co-infected
patients these values range between 43 and 71% [1,2]. The higher
PLOS ONE | www.plosone.org
1
November 2012 | Volume 7 | Issue 11 | e48959
Low versus Standard-Dose of HCV Treatment
was defined as a METAVIR fibrosis score of F2–F4 in liver biopsy
or a liver stiffness value of $8.9 kPa [21].
The current recommended treatment for genotype 3 HCV/
HIV co-infected patients is 48 weeks with Peg-IFN-a2a or PegIFN-a2b (180 mg/kg and 1.5 mg/kg per week, respectively)
combined with ribavirin (weight-adjusted) [7,8]. However, neither
duration of treatment nor drug dose have been clearly optimized.
For genotype 3 HCV monoinfected patients, the recommended
length of treatment is 24 weeks, and even 12–16 weeks for patients
achieving rapid virological response (RVR), and lower doses of
Peg-IFN/RBV have been shown to achieve similar SVR rates to
the standard dose [9–11]. However, because of the different
responses to treatment, more rapid progression to liver fibrosis,
interaction with antiretroviral treatment drugs and immunological
characteristics, the results cannot be extrapolated to HIV/HCV
co-infected patients [12,13].
Early viral kinetics gives clinicians valuable information about
the outcome of HCV treatment. Several studies have shown that
HCV viral decay in the first weeks after start of treatment can help
identify which patients will respond to treatment and which will
not [14–19]. HCV viral decline during the first weeks of treatment
is also useful for analyzing the effects of different drug doses,
including the impact on HCV clearance.
The aim of this study was to analyze the different impacts of
standard and lower-than- standard dose Peg-IFN-a2a/RBV
therapy on HCV viral decline in HIV/HCV genotype 3 coinfected patients during the first weeks after start of treatment.
Virological Evaluation
Plasma HCV RNA load measurements were conducted at
baseline and weeks 1, 2 and 4, using a quantitative PCR assay
(Cobas TaqMan, Roche Diagnostic Systems Inc., Pleasanton, CA,
USA) and using a detection limit of 15 IU/mL. Viral load was
expressed as log10IU/mL.
IL28B Genotyping
DNA was extracted using the automated MagNA Pure DNA
extraction method (Roche Diagnostics Corporation. Indianapolis,
IN 46250, USA). Single nucleotide polymorphism (SNP)
rs129679860, located 3 kilobases upstream of the IL28B, and in
strong linkage disequilibrium with a non-synonymous coding
variant in the IL28B gene (213A.G, K70R; rs81031142), was
genotyped. Genotyping was carried out using a custom TAQMAN
assay (Applied Biosystems, Foster City, California, USA) on DNA
isolated from whole blood samples, on a Stratagene MX3005
thermocycler with MXpro software (Stratagene, La Jolla, California, USA), following the manufacturer’s instructions. The
researchers responsible for genotyping were blinded to other
patient data. The IL28B genotype was defined as CC or non-CC
(TT/CT).
Statistical Analysis
Methods
Continuous variables were expressed as mean 6 standard
deviation or median (Q1–Q3) and were analyzed by the Student’s
t test, Mann-Whitney U-test or Kruskal-Wallis test. Categorical
variables were expressed as numbers of cases (percentage).
Frequencies were compared using the x2 test or Fisher’s exact
test. Significance was defined as a p value of less than 0.05. Plasma
HCV RNA decline, according to SDG and LDG dose, was
analyzed from baseline to weeks 1, 2 and 4. The effect of IL28B
genotype on HCV viral decline was also analyzed in both
treatment groups. Patients presenting an undetectable HCV viral
load at any time point during the study were excluded when
calculating reduction of HCV RNA levels at a later time. A
multivariate linear regression model was used to analyze HCV
viral decline between baseline and the various time points. In
addition, two linear regression models of HCV viral decline from
baseline to the different time points were analyzed according to
treatment group. The analysis was performed using the SPSS
statistical software package, version 18.0 (IBM Corporation,
Somers, NY, USA).
Patients, Study Design and Treatment Regimen
Two groups of HIV/HCV genotype 3 co-infected patients who
were naı̈ve to HCV treatment were included in the study.
The Standard Dose Group (SDG) included patients enrolled in
a prospective study designed to evaluate the efficacy of a treatment
strategy for chronic hepatitis C genotype 3, who were administered Peg-IFN-a2a at 180 mg/per week combined with a weightadjusted dose of ribavirin (1000 mg/day for ,75 kg, 1200 mg/
day for $75 kg); length of treatment (24 or 48 weeks) was
determined according to whether or not RVR was achieved.
The Low Dose Group (LDG) included patients enrolled in an
open-label, single-arm clinical trial (Reference: NCT00553930)
evaluating the efficacy of Peg-IFN-a2a at a dose of 135 mg/per
week combined with a daily ribavirin dose of 800 mg.
Ethical Aspects
The SDG study was designed and carried out according to the
Helsinki declaration and was approved by the Ethics Committee
of the Hospital Reina Sofia of Cordoba. (Reference:
NCT00553930). All patients were informed and signed an
informed consent form before participating in the study. The
protocol of the LDG trial and supporting CONSORT checklist
are available as supporting information; see [20]. The study
protocol was approved by the Agencia Española del Medicamento
and a central ethics committee (Comité Autonómico de Ensayos
Clı́nicos, Consejerı́a de Salud, Junta de Andalucı́a). The study was
conducted according to the Declaration of Helsinki and current
guidelines on Good Clinical Practices. This trial is registered at
NIH register (ClinicalTrials.gov: NCT00553930) and EMEA
(NuEudraCT: 2007-000814-35).
Results
One hundred and six HIV/HCV genotype 3 co-infected
patients were included in the study. Forty-eight (45.3%) patients
were included in the SDG and 58 (54.7%) in the LDG. The
baseline population characteristics of the two groups are shown in
Table 1.
HCV Viral Decline According to Treatment Group
HCV viral decline of patients given the lower dose treatment
was less than for those in the SDG, at weeks 2 and 4 after start of
treatment, although not at week 1 (week 1:1.7260.74 log10 IU/
mL versus 1.7860.67 log10 IU/mL, p = 0.827; week 2:2.360.89
log10 IU/mL versus 3.0161.02 log10 IU/mL, p = 0.013; week
4:3.5261.2 log10 IU/mL versus 4.0961.1 log10 IU/mL, p = 0.005)
(Figure 1). The multivariate linear regression models of factors
associated with HCV viral decline at weeks 1, 2 and 4 showed that
Data Collection
Host, clinical and virological characteristics were collected.
Fibrosis stage was determined by biopsy or liver transient
elastography (FibroScanH, Echosen. Paris). Significant fibrosis
2
Table 1. Baseline Population Characteristics.
Characteristic
SDG
LDG
Table 2. Multivariate linear regression model of HCV viral
decline between baseline and weeks 1, 2 and 4 after start of
treatment.
P
N
48
58
Male. N (%)
39 (81.2)
51 (87.9)
0.379
Age (years). Mean (SD)
40.4 (8.86)
43.6 (5.37)
0.612
HCV decline at week 1
Factor
Condition
B
P
SDG
20.175
0.327
0.059
0.637
Use of HAART, n (%)
45 (93.7)
52 (89.6)
0.588
Treatment Group
AIDS diagnosis in the past, n (%)
13 (27.1)
10 (17.2)
0.213
Baseline CD4 count (cells/mm3).
mean (SD)
479.9 (234.7)
496.5 (266.4) 0.743
Baseline HCV viral load (log10
IU/mL)
PIDU, n (%)
43 (89.5)
48 (82.7)
0.454
HCV baseline viral load (log10 IU/
mL). Mean (SD)
5.72 (0.75)
5.51 (1)
0.247
Liver fibrosis stage F2–F4. n (%)
32 (66.6)
33 (56.9)
0.277
Liver Cirrhosis. n (%)
12 (25)
21 (36.2)
0.253
ALT (IU/L). Mean (SD)
80.3 (47.7)
91 (57)
Significant liver fibrosis stage Yes
20.247
0.676
IL28B genotype
Non-CC
0.296
0.113
Factor
Condition
B
P
0.409
Treatment Group
SDG
0.274
0.037
0.541
0.329
0.026
147 (37)
0.325
20.113
0.340
IL28B genotype
Non-CC
20.103
0.551
LDL cholesterol (mg/dL). Mean (SD) 86.8 (33.6)
76 (29)
0.147
Platelet count (103/mL). Mean (SD) 183 (65)
176 (68)
0.654
24 (53.3){
0.409
Factor
Condition
B
P
Treatment Group
SDG
AST (IU/L). Mean (SD)
Total fasting cholesterol (mg/dL).
Mean (SD)
IL28B-CC genotype. N (%)
65.5 (35.2)
156.1 (40.4)
13 (43.4){
79.9 (33)
Standard drug dose group (SDG); low drug dose group (LDG); human
immunodeficiency virus (HIV); highly active antiretroviral treatment (HAART);
acquired immunodeficiency syndrome criteria in the past (AIDS); previous
intravenous drug user (PIDU); hepatitis C virus (HCV); interleukin 28B (IL28B).
{
Available for 30 patients. {Available for 45 patients.
doi:10.1371/journal.pone.0048959.t001
0.335
0.025
0.339
0.002
20.180
0.092
IL28B genotype
20.041
0.791
Non-CC
adjusted coefficient (B), hepatitis C virus (HCV), interleukin 28B (IL28B), standard
drug dose group (SDG). R2 = 0.327.
the steeper and sustained HCV viral decline from week 2 to week
4 was associated with a lower baseline HCV RNA viral load and
with patients in the SDG (Table 2). IL28B-CC and HCV viral
decline were not associated.
Figure 1. Mean HCV viral decline between baseline and weeks 1, 2 and 4 for the standard drug dose group (SDG) and the low drug
dose group (LDG).
doi:10.1371/journal.pone.0048959.g001
3
HCV Viral Decline According to Treatment Group and
IL28B Genotype
Table 3. Rapid virological response (RVR) rate by treatment
group and IL28B genotype.
Among SDG patients, there were no differences of HCV viral
decline by IL28B genotype at week 1 (1.8260.91 log10 IU/mL
versus 1.7460.87 log10 IU/mL, p = 0.852), week 2 (361.1 log10
IU/mL versus 3.0861.09 log10 IU/mL, p = 0.807) or week 4
(4.1460.84 log10 IU/mL versus 4.1761.06 log10 IU/mL,
p = 0.938) (Figure 2A). Similarly, no differences of HCV viral
decline by IL28B genotype were found among LDG patients at
week 1 (2.0760.47 log10 IU/mL versus 1.4261.08 log10 IU/mL,
p = 0.071), week 2 (2.4660.86 log10 IU/mL versus 2.0361.35 log10
IU/mL, p = 0.257) or week 4 (3.4460.94 log10 IU/mL versus
3.2661.01 log10 IU/mL, p = 0.573) (Figure 2B).
Among IL28B-CC genotype patients, HCV viral decline was
greater in the SDG than in the LDG at weeks 2 and 4, but not at
week 1 (week 1: p = 0.362; week 2: p = 0.051; week 4: p = 0.033).
Likewise, HCV viral decline was greater among SDG patients
carrying the IL28B non-CC genotype than among their LDG
non-CC counterparts, at weeks 2 and 4 (week 1: p = 0.343; week 2:
p = 0.034; week 4: p = 0.037).
Treatment group
IL28B genotype
RVR. N (%)
P
SDG
CC
9 (40.9)
0.748
Non-CC
12 (44.4)
LDG
CC
13 (38.2)
Non-CC
12 (35.3)
IL28B genotype
Treatment group
RVR. N (%)
P
CC
SDG
9 (40.9)
0.642
LDG
13 (38.2)
Non-CC
SDG
12 (44.4)
LDG
12 (35.3)
0.642
0.221
Interleukin 28B (IL28B), rapid virological response (RVR), standard drug dose
group (SDG), low drug dose group (LDG).
Rapid Virological Response Rate
most important factor affecting HCV viral decline in these
patients. RVR rates in our study were also higher in the SDG
compared to the LDG (72.9% versus 59.6%), although the
differences between the two groups were not statistically significant. This point should be interpreted with caution, since a better
powered cohort might be required for statistically significant
associations, due to the high RVR rate among HCV genotype 3
patients.
Reducing the dose in drug-based HCV therapy for monoinfected HCV genotype 3 patients has been studied in various
clinical trials. Firstly, reducing the dose of Peg-IFNa2a from
180 mg/per week to 135 mg/per week was shown to give similar
RVR and SVR rates [9,10]. Secondly, SVR rates did not differ
significantly according to whether a lower daily dose or a weightadjusted dose of ribavirin was used [22–24]. A reduced dose of
both drugs is, therefore, applicable to this patient population.
However, in HCV genotype 3 patients co-infected with HIV, a
low-dose Peg-IFN/RBV combination would have a considerable
impact, in terms of a high SVR, greater cost savings and fewer
adverse events than the standard dose. A previous open-label,
HCV viral load for 6 (5.6%) patients could not be evaluated at
week 4. Of the remaining 100 patients, 66 (66%) achieved RVR:
thirty-five (72.9%) in the SDG, and 31 (59.6%) in the LDG
(p = 0.174). RVR rates by treatment group and IL28B genotype
are shown in Table 3.
Discussion
In our study, HCV viral decay of patients who received lowdose Peg-IFN/RBV treatment was less during the first weeks of
treatment than for those receiving the standard Peg-IFN/RBV
dose. This finding suggests that a lower Peg-IFN/RBV dose has
less antiviral activity than the standard dose.
High viral decline during the first weeks of treatment leads to a
high RVR rate [3]. Several factors have been identified as
determining HCV viral decay [3,21]. Our study found that HCV
viral decay correlated with Peg-IFN dose in HIV/HCV genotype
3 co-infected patients, with steeper viral decline from week 2 to
week 4 in the SDG compared to the LDG. Our study also found
that the dose of Peg-IFN administered during treatment was the
Figure 2. Mean HCV viral decline by IL28B genotype for the standard dose group (SDG) (Figure 2A) and the low-dose group (LDG)
(Figure 2B).
doi:10.1371/journal.pone.0048959.g002
4
Our study has several limitations. Firstly, our study is not a
randomized clinical trial, and the presence of significant bias
cannot therefore be ruled out. Secondly, due to the higher RVR
rate in HCV genotype 2/3 patients, our study did not have the
statistical power to detect differences in RVR rate by drug
treatment dose. Thirdly, our study looked at the impact of IL28B
by determining only SNP rs12979860, although the impact
observed for this is not expected to be different from the other
known IL28B SNP (rs8099917).
In conclusion, our results show that patients who received
135 mg/per week with a 800 mg/day ribavirin dose had less HCV
viral decline in the first weeks after treatment started than those
who received 180 mg/per week with a weight-adjusted ribavirin
dose. The implications of weaker HCV viral decline in terms of
treatment outcome are unknown, although it would be expected
for a weaker HCV decline to lead to a lower RVR and
consequently to a lower SVR. In order to resolve this point, our
findings provide justification for the design of a randomized
clinical trial to compare the specific efficacy endpoints of the two
Peg-IFN/RBV doses in HIV/HCV co-infected patients. Until
such a randomized clinical trial with these specific endpoints is
conducted, therefore, clinicians should be cautious about using
lower-than-standard Peg-IFN/RBV doses in HIV/HCV genotype
3 co-infected patients.
single-arm pilot clinical trial involving 58 HCV/HIV co-infected
patients receiving low doses of Peg-IFN/RBV found that SVR
rates were 58.3% based on intention-to-treat [20]. The main
limitation of this study was the fact that it was not randomized but
a single-arm study whose results were compared with those
observed in earlier clinical trials The results of the pilot study
suggested that a lower Peg-IFN/RBV dose might be as effective as
the standard dose, so supporting the design of a randomized
controlled trial. There are no data however about the efficacy or
safety of standard Peg-IFN/RBV dose compared to a lower-than
standard dose.
To the best of our knowledge, this is the first study to compare
the efficacy of HCV viral clearance using low-dose and standarddose drug therapy in HIV/HCV co-infected patients in the first
weeks after treatment starts. Our findings suggest that the antiviral
activity of the lower Peg-IFN/RBV dose is weaker than with the
standard dose, which does not support equating the two for HIV/
HCV co-infected patients. Our results also suggest that HCV viral
decline during the first weeks of treatment would be dosedependent, although the mechanism responsible for the difference
is unknown.
In our study, we found no relation between IL28B genotype and
viral decline in either of the regimens evaluated. The positive effect
on treatment response associated with the IL28B-CC genotype has
only been observed in patients bearing genotype 1/4 [25,26]. In
fact, a previous study developed by our group reported that
variations in IL28B do not have a positive impact on HCV viral
decline in the first weeks after start of therapy using a standard
drug dose [3]. Nor did IL28B-CC have a positive effect on RVR
or SVR at standard or low drug doses in patients bearing genotype
3 [20,25].
Author Contributions
Conceived and designed the experiments: ARJ LFLC AR. Performed the
experiments: ARJ LFLC JAP A. Camacho MMS AR. Analyzed the data:
ARJ AR. Contributed reagents/materials/analysis tools: AR ARJ LFLC A.
Camacho ATC JAP MMS A. Caruz RRV JTC AGV. Wrote the paper:
ARJ AR. Critical discussion of the manuscript: AR ARJ LFLC A.
Camacho ATC JAP MMS A. Caruz RRV JTC AGV.
References
13. Operskalski E, Kovacs A (2011) HIV/HCV Co-infection: Pathogenesis, clinical
complications, treatment, and new therapeutic technologies. Curr HIV/AIDS
Rep. 8: 12–22.
14. Suzuki H, Kakizaki S, Horiguchi N, Ichikawa T, Sato K, et al. (2010) Clinical
characteristics of null responders to Peg-IFNa2b/ribavirin therapy for chronic
hepatitis C. WJH. 2: 401–405.
15. Boulestin A, Kamar N, Sandres-Saune K, Legrand-Abravanel F, Alric L, et al.
(2006) Twenty-four kinetics of hepatitis C virus and antiviral effect of alphainterferon. J Medical Virology. 78: 365–371.
16. Nomura H, Mitagi Y, Tanimoto H, Ishibashi H (2009) Impact of early viral
kinetics on pegylated interferon alpha 2b plus ribavirin therapy in Japanese
patients with genotype 2 chronic hepatitis C. J Viral Hepat. 16: 346–351.
17. Milan M, Boninsegna S, Scribano S, Lobello S, Fagiuoli S, et al. (2012) Viral
kinetics during the first weeks of pegylated interferon and ribavirin treatment can
identify patients at risk of relapse after its discontinuation: new strategies for such
patients? Infection. 40: 173–9.
18. Parruti G, Polilli E, Sozio F, Cento V, Pieri A, et al. (2010) Rapid Prediction of
sustained virological response in patients chronically infected with HCV by
evaluation of RNA decay 48 h after the start of treatment with pegylated
interferon and ribavirin. Antiviral Research. 88: 124–127.
19. Durante-Mangoni E, Zampino R, Portella G, Adinolfi LE, Utili R, et al. (2009)
Correlates and prognostic value of the first-phase hepatitis C virus RNA kinetics
during treatment. Clin Infect Dis. 49: 498–506.
20. Lopez-Cortes LF, Ruiz-Valderas R, Jimenez-Jimenez L, González-Escribano
MF, Torres-Cornejo A, et al; on behalf of the Grupo para el estudio de las
hepatitis vı́ricas (HEPAVIR) de la Sociedad Andaluza de Enfermedades
Infecciosas (SAEI). (2012) Influence of IL28B polymorphisms on response to a
lower-than-standard dose peg-IFN-a-2a for genotype 3 chronic hepatitis C in
HIV-coinfected patients. Plos ONE. 7: e28115. Doi:10.1371/journal.pone.0028115.
21. Macias J, Recio E, Vispo E, Rivero A, López-Cortés LF, et al. (2008)
Application of transient elastometry to differentiate mild from moderate to
severe fibrosis in HIV/HCV co-infected patients. J Hepatol. 49: 916–22.
22. Pockros PJ, Carithers R, Desmond P, Dhumeaux D, PEGASYS International
Study Group, et al. (2004) Efficacy and safety of two-dose regimens of
peginterferon alpha-2a compared with interferon alpha-2a in chronic hepatitis
C: a multicenter randomized controlled trial. Am J Gastroenterol. 99: 971–81.
1. Chung RT, Andersen J, Volberding P, Robbins GK, Liu T, et al. (2004)
Peginterferon alfa-2a plus ribavirin versus interferon alfa-2a plus ribavirin for
chronic hepatitis C in HIV coinfected Persons. N Engl J. Med. 351: 451–459.
2. Torriani F, Rodriguez-Torres M, Rockstroh J, Lissen E, Gonzalez-Garcı́a J, et
al. (2004) Peginterferon alfa-2a plus ribavirin for chronic hepatitis C virus
infection in HIV-infected patients. N Engl J Med. 351: 438–450.
3. Rivero-Juarez A, Camacho A, Perez-Camacho I, Neukam K, Caruz A, et al.
(2012) Association between the IL28B genotype and hepatitis C viral kinetics in
the early days of treatment with pegylated interferon plus ribavirin in HIV/
HCV co-infected patients with genotype 1 or 4. J Antimicrob Chemother. 67:
202–5.
4. Bochoud PY, Cai T, Overbeck K, Bochud M, Dufour JF, et al. (2009) Genotype
3 is associated with accelerated fibrosis progression in chronic hepatitis C. J
Hepatol. 51: 655–66.
5. Probst A, Dang T, Bochud M, Egger M, Negro F, et al. (2011) Role of hepatitis
C virus genotype 3 in liver fibrosis progression: a systematic review and metaanalysis. J Viral Hepat. 18: 745–59.
6. Nkontchou G, Ziol M, Aout M, Lhabadie M, Baazia Y, et al. (2011) HCV
genotype 3 is associated with a higher hepatocellular carcinoma incidence in
patients with ongoing viral C cirrhosis. J Viral Hepat. 18: e516–22. doi:
10.1111/j.1365-2893.2011.01441.x.
7. Ghany MG, Strader DB, Thomas DL, Seeff LB (2009) Diagnosis, Management
and Treatment of Hepatitis C: An update. AASLD Practice Guidelines.
Hepatology. 49: 1335–1374.
8. Sulkowski MS (2008) Viral hepatitis and HIV coinfection. J Hepatol. 48: 353–
367.
9. McHutchison JG, Lawitz EJ, Shiffman ML, Muir AJ, Galler GW, et al. (2009)
Peginterferon alfa-2b or alfa-2a with ribavirin for treatment of hepatitis C
infection. N Engl J Med. 361: 580–93.
10. Fried MW, Shiffman ML, Reddy KR, Smith C, Marinos G, et al. (2002)
Peginterferon alfa-2a plus ribavirin for chronic hepatitis C virus infection. N
Engl J Med. 347: 975–82.
11. Weiland O, Hollander A, Mattson L, Glaumann H, Lindahl K, et al. (2008)
Lower-than-standard dose peg-IFN alfa-2a for chronic hepatitis C caused by
genotype 2 and 3 is sufficient when given in combination with weight-based
ribavirin. J Viral Hepat. 15: 641–5.
12. Soriano V, Vispo E, Labarga P, Medrano J, Barreiro P (2010) Viral hepatitis and
HIV co-infection. Antiviral Res. 85: 303–315.
5
23. Jacobson IM, Brown RS, Freilich B, Afdhal N, WIN-R Study Group, et al.
(2007) Peginterferon alfa-2b and weight-based or flat-dose ribavirin in chronic
hepatitis C patients: a randomized trial. Hepatology; 46: 971–81.
24. Ferenci P, Brunner H, Laferl H, Scherzer TM, Austrian Hepatitis Study Group,
et al. (2008) A randomized, prospective trial of ribavirin 400 mg/day versus
800 mg/day in combination with peginterferon alfa-2a in hepatitis C virus
genotype 2 and 3. Hepatology. 47: 1816–23.
25. Pineda JA, Caruz A, Rivero A, Neukam K, Salas I, et al. (2010) Prediction of
response to pegylated interferon plus ribavirin by IL28B gene variation in
patients coinfected with HIV and hepatitis C virus. Clin Infect Dis. 51: 788–95.
26. Ge D, Fellay J, Thompson AJ, Simon JS, Shianna KV, et al. (2009) Genetic
variation in IL28B predicts hepatitis C treatment-induced viral clearance.
Nature. 461: 399–401.
6
Infection
DOI 10.1007/s15010-012-0352-4
CLINICAL AND EPIDEMIOLOGICAL STUDY
Baseline risk factors for relapse in HIV/HCV co-infected patients
treated with PEG-IFN/RBV
A. Rivero-Juarez • J. A. Mira • A. Camacho •
K. Neukam • I. Perez-Camacho • A. Caruz • J. Macias
J. Torre-Cisneros • J. A. Pineda • A. Rivero
•
Received: 9 January 2012 / Accepted: 3 October 2012
Ó Springer-Verlag Berlin Heidelberg 2012
Abstract
Purpose Hepatitis C virus (HCV) viral relapse (VR) after
end-of-treatment response (ETR) in human immunodeficiency virus (HIV) co-infected patients is observed in as
many as one in three co-infected patients. The aim of the
study was to identify baseline risk factors for VR in HIV/
HCV co-infected patients treated with pegylated interferon
plus ribavirin (PEG-INF/RBV).
Methods A total of 212 Caucasian HIV-infected patients
with chronic hepatitis C naı̈ve for PEG-INF/RBV were
followed prospectively. Patients were included in this
prospective study if they had completed a full course of
therapy with an ETR. We assessed the relationship between
VR rate and potential predictors of relapse.
Results Of the patients followed, 130 (61.3 %) attained
ETR and 103 (79.2 %) achieved sustained virological
response (SVR). Consequently, 27 (20.8 %) showed VR.
Patients who relapsed were more often male (p = 0.036),
A. Rivero-Juarez (&) A. Camacho J. Torre-Cisneros A. Rivero (&)
Unidad de Enfermedades Infecciosas, Instituto Maimonides de
Investigación Biomédica de Córdoba (IMIBIC),
Hospital Universitario Reina Sofia, Córdoba, Spain
e-mail: [email protected]
A. Rivero
e-mail: [email protected]
J. A. Mira K. Neukam J. Macias J. A. Pineda
Unidad de Enfermedades Infecciosas, Hospital Universitario
Virgen de Valme, Sevilla, Spain
I. Perez-Camacho
Hospital de Poniente, El Ejido, Almerı́a, Spain
A. Caruz
Departamento de Biologı́a Molecular, Universidad de Jaen, Jaén,
Spain
carried the non-CC rs14158 genotype in the low-density
lipoprotein receptor (LDLr) gene (p = 0.039), had higher
baseline HCV RNA levels (p = 0.012), body mass index
(BMI) C25 kg/m2 (p = 0.034), significant liver fibrosis
(p \ 0.001), had been diagnosed with acquired immunodeficiency syndrome (AIDS)-defining criteria in the past
(p = 0.001) and bore the HCV genotypes 1/4 (p = 0.046)
when compared with SVR patients. The IL28B genotype
was not associated with relapse. Multivariate binary
logistic regression showed that high baseline HCV RNA,
significant liver fibrosis, HCV genotypes 1/4, being overweight and being diagnosed with AIDS-defining criteria in
the past were independently associated with relapse.
Conclusions Our study shows that VR can be accurately
predicted in HIV/HCV co-infected patients on the basis of
risk factors which can be identified before treatment.
Keywords HCV HIV End-of-treatment response Viral relapse Risk factors
Introduction
Chronic hepatitis C virus (HCV) infection is a worldwide
health problem that affects over 170 million people and
induces significant morbidity and mortality [1]. Approximately 4–5 million of these patients are co-infected with
human immunodeficiency virus (HIV). Treating HCV in
HIV co-infected patients is a priority, since these patients
progress more rapidly to end-stage liver disease, have poor
tolerance to antiretroviral treatment and are at greater risk
of hepatotoxicity [2, 3].
Pegylated interferon plus ribavirin (PEG-IFN/RBV) is
currently the standard treatment for HCV infection. HCV
treatment is less effective in HIV/HCV co-infected patients
123
A. Rivero-Juarez et al.
than in HCV monoinfected patients [4]. The reasons for
these differences are unclear, although a higher relapse rate
following completion of a course of therapy may contribute
to lower sustained virological response (SVR) rates [5].
Indeed, a high proportion of HIV/HCV co-infected patients
with an end-of-treatment response (ETR) experience viral
relapse (VR) [5, 6]. In some studies, VR is observed in as
many as one in three co-infected patients, even among
those infected with HCV genotype 3 [7].
The aim of this study was to identify baseline risk factors for HCV relapse in HIV/HCV co-infected patients
treated with PEG-IFN/RBV.
dose of oral ribavirin (1,000 mg per day for \75 kg,
1,200 mg per day for C75 kg). Patients with HCV genotypes 1/4 received either 48 or 72 weeks of treatment,
while patients with HCV genotype 3 received 24 or
48 weeks of treatment, depending on the decision of the
physician responsible for the patient [8]. At weeks 12 and
24, PEG-IFN/RBV was discontinued in non-responders.
Definitions of virological responses
Methods
ETR and SVR were defined as an undetectable serum HCV
RNA level at completion of treatment and 24 weeks after
the end of treatment, respectively. VR was defined as an
undetectable serum HCV RNA level at the end of treatment, but detectable at the 24-weeks post-treatment date.
Patients
Caucasian HIV-infected patients with chronic hepatitis C
bearing a single genotype and receiving a combination
therapy of PEG-IFN/RBV were followed prospectively at
two reference hospitals in Spain, from January 2007 to
June 2010. All patients were treatment-naı̈ve for HCV. The
criteria used to manage hepatitis C therapy were in
accordance with international guidelines [8]. Patients were
included in this study if they had completed a full course of
therapy with ETR and the 24-week post-treatment evaluation of serum HCV RNA. Patients who tested positive for
hepatitis B surface antigen (HBsAg) were excluded.
Plasma HCV RNA load measurements were performed
using a quantitative polymerase chain reaction (PCR) assay
(COBAS TaqMan, Roche Diagnostic Systems, Inc., Pleasanton, CA, USA), with a detection limit of 15 IU/mL. The
HCV genotype was determined using a hybridisation assay
(INNO-LiPa HCV, Bayer Corp., Tarrytown, NY, USA).
Single nucleotide polymorphism genotyping
Baseline host characteristics [age, body mass index (BMI),
sex, low-density lipoprotein receptor (LDLr) and interleukin 28B (IL28B) genotype], baseline virological characteristics (viral load and HCV genotyping) and baseline
characteristics concerning HIV infection [use of highly
active antiretroviral therapy (HAART), CD4 cell count and
acquired immunodeficiency syndrome (AIDS)-defining
criteria in the past] were recorded.
DNA was extracted using the automated MagNA Pure
DNA extraction method (Roche Diagnostics Corp., Indianapolis, IN, USA). Single nucleotide polymorphism (SNP)
rs14158 in the 30 UTR of the LDLr gene and 129679860,
located 3 kb upstream of the IL28B genotype, and with a
strong linkage disequilibrium with a non-synonymous
coding variant in the IL28B gene (213A[G, K70R;
rs81031142) were genotyped. Genotyping was carried out
using a custom TAQMan assay (Applied Biosystems,
Foster City, CA, USA) on DNA isolated from whole-blood
samples. A Stratagene MX3005 thermocycler was used
with MXpro software (Stratagene, La Jolla, CA, USA),
following the manufacturer’s instructions.
Liver fibrosis evaluation
Fibrosis stage was determined by biopsy or liver transient
elastography (FibroScanÒ, Echosens, Paris, France). Significant fibrosis was defined as a METAVIR fibrosis score of F2–
F4 in liver biopsy or a liver stiffness (LS) value of C8.9 kPa.
We assessed the relationship between VR rate and the
following parameters: sex (male vs. female); BMI (\25 vs.
C25 kg/m2); liver fibrosis stage (F0–F1 or LS \ 8.9 kPa
vs. F2–F4 or LS C 8.9 kPa); IL28B genotype (CC vs. nonCC); LDLr genotype (CC vs. non-CC); age; AIDS-defining
condition in the past (no vs. yes) [9]; HAART (use vs. nonuse); CD4 cell count (B250 vs. [250 cells/mL); PEG-IFN
(a2a vs. a2b); HCV genotype (1/4 vs. 2/3); HCV genotype
1 subtypes (1a vs. 1b); and baseline HCV RNA level
(C600,000 vs. \600,000 IU/mL).
Data analysis
Treatment regimens
All individuals were treated with either PEG-IFN a2a or
PEG-IFN a2b, at doses of 180 or 1.5 lg/kg per week,
respectively, in combination with a body weight-adjusted
123
Baseline risk factors for relapse in HIV/HCV patients
The descriptive statistics for patient characteristics were
reported. Continuous variables were summarised as
mean ± standard deviation and categorical variables as
frequencies and percentages. Statistical significance for
continuous variables was analysed by the Student’s t-test or
the Mann–Whitney U-test. The Chi-square or Fisher’s
exact test were used for categorical variables. A stepwise
logistic regression analysis was conducted as the multivariate analysis. Statistical analyses were carried out using
SPSS software (version 18, SPSS Inc., Chicago, IL, USA).
Table 1 Comparison of the characteristics of patients achieving
sustained virological response (SVR) against patients who experienced viral relapse (VR) (p-value compares SVR and VR in each
category)
ETR
(n = 130)
SVR
(n = 103)
VR
(n = 27)
p-value
Male
106 (81.5)
80 (75.5)
26 (24.5)
0.036
Female
24 (18.5)
23 (95.8)
1 (4.1)
25.7 ± 3.8
25.6 ± 3.7
25.9 ± 4.2
0.478
\25 kg/m2
101 (77.7)
83 (82.2)
18 (17.8)
0.034
C25 kg/m2
29 (22.3)
20 (69)
9 (31)
Sex, n (%)
BMI, mean ± SD
BMI, n (%)
Ethical aspects
This study was designed and performed according to the
Helsinki declaration and was approved by the Ethical
Committees of both participating hospitals.
Results
Significant liver fibrosis, n (%)
Yes
80 (61.5)
58 (72.5)
22 (27.5)
No
50 (38.5)
45 (90)
5 (10)
\0.001
Use of HAART, n (%)
Yes
116 (89.2)
92 (81.1)
24 (20.69)
No
14 (10.8)
11 (78.5)
3 (21.5)
40.9 ± 5.4
40.9 ± 5.6
41.2 ± 5.1
0.79
0.001
Age (years), mean ± SD
0.915
AIDS-defining condition in the past, n (%)
A total of 212 treatment-naı̈ve HIV/HCV co-infected
patients were included in the study, with 137 (64.6 %) and
75 (35.4 %) bearing genotypes 1/4 and 3, respectively. Of
these individuals, 130 patients (61.3 %) had ETR; 103
(79.2 %) of them achieved SVR and 27 (20.8 %) presented
VR, and were included in the analysis. The baseline and
relapse HCV genotype was the same in all patients that
experienced VR. HCV genotype 3 patients had a higher
rate of ETR than genotypes 1/4 patients (p \ 0.001).
The baseline characteristics of the 130 individuals who
achieved ETR and were included in the analysis are presented in Table 1.
Risk factors identified by the univariate analysis were
included in the multivariate binary logistic regression. The
following factors were significantly associated with relapse
in the multivariate analysis: a high baseline HCV RNA
(C600,000 IU/mL) level; significant liver fibrosis (F2–F4);
HCV genotypes 1/4; BMI C25 kg/m2; and AIDS-defining
criteria in the past (Table 2).
No
73 (56.2)
67 (91.8)
6 (8.2)
Yes
57 (43.8)
36 (63.2)
21 (36.8)
CD4 cell count, n (%)
\250 cells/mL
16 (12.4)
12 (75)
4 (25)
C250 cells/mL
114 (87.6)
91 (79.8)
23 (20.2)
a2a
90 (69.2)
70 (77.8)
20 (22.2)
a2b
40 (30.7)
34 (85)
6 (15)
0.632
PEG-IFN, n (%)
0.156
HCV genotype
1/4
64 (49.2)
46 (71.9)
18 (28.1)
3
66 (50.8)
57 (86.3)
9 (13.7)
1a
26 (61.9)
15 (57.7)
11 (42.3)
1b
16 (38.1)
12 (75)
4 (25)
\600,000 IU/mL
62 (47.7)
55 (88.7)
7 (12.3)
C600,000 IU/mL
68 (52.3)
48 (70.6)
20 (29.4)
CC
62 (59)
51 (82.2)
11 (17.8)
Non-CC
43 (41)
33 (76.7)
10 (23.2)
CC
64 (64)
54 (84.4)
10 (15.6)
Non-CC
36 (36)
26 (72.2)
10 (27.8)
0.046
HCV genotype 1
0.279
Baseline HCV RNA level
0.012
IL28B genotype, n (%)a
0.498
LDLr genotype, n (%)b
Discussion
This study identifies factors that contribute to VR in HIV/
HCV co-infected patients treated with PEG-IFN/RBV.
Factors that were significantly associated with relapse
included: significant liver fibrosis, high baseline serum
HCV RNA, AIDS-defining criteria in the past,
BMI C25 kg/m2 and HCV genotypes 1/4. The IL28B nonCC genotype, however, was not a predictor of relapse.
Advanced liver fibrosis has been identified as a risk
factor for non-response in HCV infected patients, while the
association between significant liver fibrosis and relapse
0.039
SD standard deviation (SD); BMI body mass index; HAART highly active
antiretroviral therapy; PEG-INF pegylated interferon; IL28B interleukin 28B;
LDLr low-density lipoprotein receptor
a
Available in 105 patients
b
Available in 100 patients
has not been firmly established [10, 11]. Thus, Cheng et al.
[12] demonstrated that relapse rates for HCV monoinfected
patients markedly increased with advanced fibrosis (F0,
16 %; F1, 23 %; F2, 26 %; F3, 50 %; F4, 80 %,
p \ 0.001). However, Shin et al., in a cohort of 242
treatment-naı̈ve HCV monoinfected patients achieving
123
Table 2 Multivariate analysis
of risk factors for relapse
OR odds ratio, CI confidence
interva, BMI body mass index,
LDLr low-density lipoprotein
receptor
Factors
Condition
OR (95 % CI)
Multivariate
p-value
Baseline serum HCV RNA level
C600,000 IU/mL
2.17 (1.2–7.9)
0.023
Liver fibrosis stage
Significant
5.97 (2.1–11.9)
0.002
HCV genotype
1 or 4
1.97 (1.01–5.91)
0.04
LDLr
Non-CC
1.78 (0.39–3.61)
0.143
Sex
Male
1.1 (0.31–1.98)
0.24
BMI
C25 kg/m2
1.6 (1.1–2.7)
0.047
Previous AIDS-defining condition
Yes
ETR, did not identify advanced liver fibrosis as a risk
factor for relapse [13]. Nevertheless, the latter study is
limited in this respect, since the liver fibrosis stage was
only determined in 35.9 % of patients. An association
between significant liver fibrosis and a higher rate of
relapse has not been established for HIV/HCV co-infected
patients. In the PRESCO study, significant liver fibrosis
was not identified as a risk factor for relapse, although the
stage of liver fibrosis in this study could only be determined in 32.8 % of patients [7]. In our study, HIV/HCV
co-infected patients with a liver fibrosis score of F2–F4 had
a higher VR rate than those with a score of F0–F1;
moreover, significant liver fibrosis was the strongest risk
factor for VR.
High baseline serum HCV RNA level is a known risk
factor for relapse in both HIV/HCV co-infected and HCV
monoinfected patients, despite the variable thresholds used
in different studies for considering high serum HCV RNA.
Using a relatively high threshold for high serum HCV RNA
(2,000,000 IU/mL), Shin et al. [13] identified high HCV
RNA as a risk factor for relapse in monoinfected Korean
patients with HCV genotypes 1/4. On the other hand,
Deschênes et al. [14] used a relatively low threshold
(400,000 IU/mL) for a cohort of 432 treatment-naı̈ve HCV
genotype 1 monoinfected patients with ETR, and found that
patients with high HCV baseline viral loads had higher
relapse rates (86 vs. 66 %, p = 0.001). The same relationship between high serum HCV RNA level and relapse rate
has been demonstrated for HIV/HCV co-infected patients.
Thus, Núñez et al. [7] identified high serum HCV RNA as
the highest risk factor for relapse in Caucasian HIV/HCV
co-infected patients [relative risk (RR) 4.81 (95 % CI;
1.52–15.22)], using a threshold of 500,000 IU/mL. Our
study, using a cut-off point of 600,000 IU/mL, confirms
these results and identifies high serum HCV RNA as a risk
factor for relapse in HIV/HCV co-infected patients.
Several clinical trials conducted on HIV/HCV coinfected patients have shown that patients with HCV
genotypes 1/4 have higher rates of relapse than those
bearing HCV genotype 3. In the Adult AIDS Clinical Trials
Group (ACTG) protocol 5071, Chung et al. [15] observed
123
3.86 (1.92–10.23)
0.01
that patients with HCV genotype 1 who received PEG-INF/
RBV had higher relapse rates than those with a non-1
genotype (33.3 vs. 4.3 %, p = 0.031). In the RIBAVIC
trial, there was a higher relapse rate for HIV/HCV coinfected patients with genotypes 1/4 who received PEGINF/RBV than for patients bearing genotypes 2/3 (33.3 vs.
12.5 %, p = 0.04) [16]. Similar results were obtained (23.8
vs. 3.2 %, p = 0.001) in the APRICOT trial [17]. Our
study supports these findings and shows that, for the coinfected HIV/HCV patient, the HCV genotypes 1/4 are risk
factors for relapse.
Our study shows that being overweight might be associated with a higher relapse rate. When Rodrı́guez-Torres
et al. [18] studied a cohort of 35 Hispanic origin patients
bearing HCV genotypes 2/3, they found a difference—
albeit not statistically significant—in the VR rate between
patients weighing[75 kg and those weighing less (28.6 vs.
14.3 %, p = 0.088). Previous studies have shown that a
suboptimal dose of ribavirin is an important cause of VR,
so weight-based ribavirin is recommended in order to
reduce the virologic relapse rate [19]. A possible explanation for this finding might be that inadequate therapeutic
ribavirin dosing is more likely in overweight patients.
However, in our study, all patients were treated with
weight-adjusted doses of oral ribavirin. On the other hand,
suboptimal PEG-IFN dosing is more likely in overweight
patients using standard doses of PEG-IFN a2a, which
might favour VR, although there are also studies showing
that BMI predicts relapse with weight-based doses of PEGIFN a2b [20–22]. These findings point to explanations
other than the ribavirin or PEG-IFN dose.
In our study, there were higher relapse rates for patients
with AIDS-defining criteria in the past. Information about
the relationship between VR and more advanced HIV
disease is scarce. Núñez et al. [7] pointed out that relapse
rates in HIV/HCV co-infected patients using antiretroviral
therapy were higher than in those who did not use it (80.6
and 67.4 %, respectively, p = 0.046), although the authors
hypothesised that the influence was not directly associated
with the use of HAART but, rather, with more advanced
stages of HIV disease, in line with the criteria used in the
Baseline risk factors for relapse in HIV/HCV patients
past for beginning antiretroviral therapy. Our study supports this hypothesis, because patients with AIDS-defining
criteria in the past, but not those on HAART, had a higher
risk of relapse. This finding, if confirmed in further studies,
suggests that an advanced stage of HIV disease may be a
risk factor for relapse. The cause of high VR rates among
patients with more advanced HIV disease remains uncertain. A possible explanation for this finding could be that
patients with previous symptomatic HIV disease may have
an associated loss of immune function involved in HCV
clearance, which may determine the higher rate of relapse.
Studies are needed in order to confirm this point.
The IL28B genotype has been identified as a strong
predictor of SVR in both HCV monoinfected and HIV coinfected patients [22, 23]. However, information about the
relationship between the IL28B genotype and VR is scarce.
It has recently been reported that variations in the IL28B
genotype are not associated with viral relapse in HCV
monoinfected and co-infected patients treated with PEGIFN/RBV [22, 24]. Our study corroborates this finding,
showing that patients who carry the IL28B non-CC genotype did not have higher relapse rates than those with the
IL28B-CC genotype.
According to a previous study carried out by our group,
patients carrying the non-CC LDLr genotype were more
likely to suffer a relapse (13 vs. 30 %, p = 0.023) [25].
However, the present study shows that, although the nonCC LDLr genotype was associated with a higher percentage of relapses, the relationship was not confirmed in the
logistic regression model. For this reason, our study cannot
be used for demonstrating a correlation between LDLr
genotype and percentage of relapses. In this study, one of
the groups derived as the result of categorising the presence
or not of relapse as a dependent variable contained only 27
patients. Consequently, our logistic regression model might
fail to identify variables which could, in fact, be associated
with relapse, due to its lack of power. A better powered
study could help clarify the possible relationship.
Our study has several limitations. This study confirmed
that the baseline and relapse HCV genotype was the same in
all patients, although we did not perform a comparative
genome study of the virus at both these time-points.
Therefore, reinfection and superinfection reactivation could
not be dismissed entirely [26, 27]. Second, the standard of
care for HCV treatment is due to change for HIV/HCV
genotype 1 patients in the coming years. The incorporation
of the new protease inhibitors, boceprevir and telaprevir, to
PEG-IFN/RBV will improve the rate of treatment response
in this group of patients, as has been the case with HCV
monoinfected patients [28–31]. Our study shows the risk
factors for relapse using the current HIV/HCV standard of
care, so that those risk factors identified in our study may
have limited power with those patients who add the new
protease inhibitors to the standard of care. Studies are
needed in order to analyse the baseline risk factors for
relapse in patients receiving boceprevir or telaprevir.
In conclusion, our study shows that VR in HIV/HCV coinfected patients can be predicted on the basis of risk
factors (significant liver fibrosis, HCV baseline viral load
C600,000 IU/mL, BMI C25 kg/m2, HCV genotypes 1/4
and AIDS-defining criteria in the past) which can be
identified prior to treatment. This may allow physicians to
evaluate alternative treatment strategies for patients at high
risk of relapse.
Acknowledgments This work was partly supported by grants from
the Fundación Progreso y Salud, Consejerı́a de Salud de la Junta de
Andalucı́a (grants for health research projects, references: 0036/2010,
PI-0247-2010 and PI-0208 and 0124/2008) and the Spanish Health
Ministry (ISCIII-RETIC RD06/006, and projects PI10/0164 and PI10/
01232). A.R. is the recipient of a research extension grant from the
Fundación Progreso y Salud, Consejerı́a de Salud de la Junta de
Andalucı́a (reference AI-0011-2010), J.A.P. is the recipient of an
extension grant from the Fundación Progreso y Salud of the Consejerı́a de Salud de la Junta de Andalucı́a (reference AI-0021) and K.N.
is the recipient of a Sara Borrell postdoctoral perfection grant from
the Instituto de Salud Carlos III (SCO/523/2008).
Conflict of interest The authors have no conflicts of interest to
declare. A.R. has received consulting fees from Bristol-Myers Squibb,
Abbott, Gilead, Roche and Boehringer Ingelheim. J.A.P. has received
consulting fees from GlaxoSmithKline, Bristol-Myers Squibb,
Abbott, Gilead, Merck Sharp & Dohme, Janssen-Cilag and Boehringer Ingelheim. They have received research support from GlaxoSmithKline, Roche, Bristol-Myers Squibb, Schering-Plough, Abbott
and Boehringer Ingelheim, and lecture fees from GlaxoSmithKline,
Roche, Abbott, Bristol-Myers Squibb, Boehringer Ingelheim and
Schering-Plough. The remaining authors have no conflicts of interest
to declare.
References
1. Lauer GM, Walker BD. Hepatitis C virus infection. N Engl J
Med. 2011;345:41–52.
2. Operskalski EA, Kovacs A. HIV/HCV co-infection: pathogenesis, clinical complications, treatment, and new therapeutic technologies. Curr HIV/AIDS Rep. 2011;8:12–22.
3. Soriano V, Vispo E, Labarga P, Medrano J, Barreiro P. Viral
hepatitis and HIV co-infection. Antivir Res. 2010;85:303–15.
4. Hadigan C, Kottilil S. Hepatitis C virus infection and coinfection
with human immunodeficiency virus: challenges and advancements in management. JAMA. 2011;306:294–301.
5. Soriano V, Pérez-Olmeda M, Rı́os P, Núñez M, Garcı́a-Samaniego J, González-Lahoz J. Hepatitis C virus (HCV) relapses after
anti-HCV therapy are more frequent in HIV-infected patients.
AIDS Res Hum Retroviruses. 2004;20:351–3.
6. Medrano J, Barreiro P, Resino S, et al. Rate and timing of hepatitis C virus relapse after a successful course of pegylated
interferon plus ribavirin in HIV-infected and HIV-uninfected
patients. Clin Infect Dis. 2009;49:1397–401.
7. Núñez M, Mariño A, Miralles C, et al. Baseline serum hepatitis C
virus (HCV) RNA level and response at week 4 are the best
predictors of relapse after treatment with pegylated interferon
123
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
plus ribavirin in HIV/HCV-coinfected patients. J Acquir Immune
Defic Syndr. 2007;45:439–44.
Ghany MG, Strader DB, Thomas DL, Seeff LB; American
Association for the Study of Liver Diseases. Diagnosis, management, and treatment of hepatitis C: an update. AASLD practice guidelines. Hepatology. 2009;49:1335–74.
Centers for Disease Control and Prevention (CDC). Revised
surveillance case definitions for HIV infection among adults,
adolescents, and children aged\18 months and for HIV infection
and AIDS among children aged 18 months to\13 years—United
States, 2008. MMWR Recomm Rep. 2008;57:1–8.
Medrano J, Neukam K, Rallón N, et al. Modeling the probability
of sustained virological response to therapy with pegylated
interferon plus ribavirin in patients coinfected with hepatitis C
virus and HIV. Clin Infect Dis. 2010;15:1209–16.
Shirakawa H, Matsumoto A, Joshita S, et al. Pretreatment prediction of virological response to peginterferon plus ribavirin
therapy in chronic hepatitis C patients using viral and host factors. Hepatology. 2008;48:1753–60.
Cheng WS, Roberts SK, McCaughan G, et al. Low virological
response and high relapse rates in hepatitis C genotype 1 patients
with advanced fibrosis despite adequate therapeutic dosing.
J Hepatol. 2010;53:616–23.
Shin SR, Sinn DH, Gwak GY, et al. Risk factors for relapse in
chronic hepatitis C patients who have achieved end of treatment
response. J Gastroenterol Hepatol. 2010;25:957–63.
Deschênes M, Bain VG, Lee SS, et al. Identifying HCV genotype
1 patients at risk of relapse. Eur J Gastroenterol Hepatol. 2010;
22:546–51.
Chung RT, Andersen J, Volberding P, et al. Peginterferon alfa-2a
plus ribavirin versus interferon alfa-2a plus ribavirin for chronic
hepatitis C in HIV-coinfected persons. N Engl J Med. 2004;351:
451–9.
Carrat F, Bani-Sadr F, Pol S, et al. Pegylated interferon alfa-2b vs
standard interferon alfa-2b, plus ribavirin, for chronic hepatitis C
in HIV-Infected patients: a randomized controlled trial. JAMA.
2004;292:2839–48.
Torriani FJ, Rodriguez-Torres M, Rockstroh JK, et al. Peginterferon alfa-2a plus ribavirin for chronic hepatitis C virus infection
in HIV-infected patients. N Engl J Med. 2004;351:438–50.
Rodrı́guez-Torres M, Rı́os-Bedoya CF, Ortiz-Lasanta G, et al.
Weight affect relapse rates in latinos with genotype 2/3 chronic
hepatitis C (CHC) treated with peg IFN alfa-2a (Pegasys) 180
mcg/week and 800 mg daily of ribavirin for 24 weeks. J Med
Virol. 2008;80:1576–80.
Jacobson IM, Brown RS Jr, Freilich B, et al. Peginterferon alfa2b and weight-based or flat-dose ribavirin in chronic hepatitis C
patients: a randomized trial. Hepatology. 2007;46:971–81.
123
20. Mangia A, Santoro R, Minerva N, et al. Peginterferon alfa-2b and
ribavirin for 12 vs. 24 weeks in HCV genotype 2 or 3. N Engl J
Med. 2005;352:2609–17.
21. Jian Wu Y, Shu Chen L, Gui Qiang W. Effects of fatty liver and
related factors on the efficacy of combination antiviral therapy in
patients with chronic hepatitis C. Liver Int. 2006;26:166–72.
22. Pineda JA, Caruz A, Rivero A, et al. Prediction of response to
pegylated interferon plus ribavirin by IL28B gene variation in
patients coinfected with HIV and hepatitis C virus. Clin Infect
Dis. 2010;51:788–95.
23. Thompson AJ, Muir AJ, Sulkowski MS, et al. Interleukin-28B
polymorphism improves viral kinetics and is the strongest pretreatment predictor of sustained virologic response in genotype 1
hepatitis C virus. Gastroenterology. 2010;139:120–9.
24. Wiegand J, Neumann K, Böhm S, et al. Prediction of relapse after
peginterferon alfa-2b/ribavirin therapy in chronic HCV genotype
1 patients is dependent on minimal residual virema but not on
il28b genotype. In: 46th annual meeting of the European Association for the Study of the Liver, Berlin, Germany, March 30–
April 3 2011.
25. Pineda JA, Caruz A, Di Lello FA, et al. Low-density lipoprotein
receptor genotyping enhances the predictive value of IL28B
genotype in HIV/hepatitis C virus-coinfected patients. AIDS.
2011;25:1415–20.
26. Grebely J, Pham ST, Matthews GV, et al. Hepatitis C virus
reinfection and superinfection among treated and untreated participants with recent infection. Hepatology. 2012;55:1058–69.
27. van de Laar TJ, Molenkamp R, van den Berg C, et al. Frequent
HCV reinfection and superinfection in a cohort of injecting drug
users in Amsterdam. J Hepatol. 2009;51:667–74.
28. Poordad F, McCone J Jr, Bacon BR, et al. Boceprevir for
untreated chronic HCV genotype 1 infection. N Engl J Med.
2011;364:1195–206.
29. Jacobson IM, McHutchison JG, Dusheiko G, et al. Telaprevir for
previously untreated chronic hepatitis C virus infection. N Engl J
Med. 2011;364:2405–16.
30. Dieterich D, Soriano V, Sherman K, et al. Telaprevir in combination with pegylated interferon-a-2a ? ribavirin in HCV/HIVco-infected patients: a 24-week treatment interim analysis. In:
19th Conference on Retroviruses and Opportunistic Infections
(CROI), Seattle, USA, March 2012. Oral abstract 46.
31. Sulkowski M, Pol S, Cooper C, et al. Boceprevir ? pegylated
interferon ? ribavirin for the treatment of HCV/HIV-co-infected
patients: end of treatment (week 48) interim results. In: 19th
Conference on Retroviruses and Opportunistic Infections (CROI),
Seattle, USA, March 2012. Oral abstract 47.
AID-2012-0126-ver9-Rivero-Juarez_1P.3d
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AID-2012-0126-ver9-Rivero-Juarez_1P
Type: rapid-communication
AIDS RESEARCH AND HUMAN RETROVIRUSES
Volume 28, Number 00, 2012
ª Mary Ann Liebert, Inc.
DOI: 10.1089/aid.2012.0126
Atazanavir-Based Therapy Is Associated
with Higher Hepatitis C Viral Load
in HIV Type 1-Infected Subjects with Untreated Hepatitis C
Antonio Rivero-Juarez,1,2 Jose A. Mira,3,4 Ignacio Santos-Gil,5 Luis F. Lopez-Cortes,6,7
Jose A Girón-Gonzalez,8 Manuel Marquez,9 Dolores Merino,10 Francisco Tellez,11
Antonio Caruz,12 Juan A Pineda,2 and Antonio Rivero1,2
on behalf of the Grupo Andaluz para el Estudio de las Hepatitis Vı́ricas (HEPAVIR)
de la Sociedad Andaluza de Enfermedades Infecciosas (SAEI)
Abstract
We assessed the relationship between atazanavir (ATV)-based antiretroviral treatment (ART) and plasma
hepatitis C virus (HCV) viral load in a population of HIV/HCV-coinfected patients. HIV/HCV-coinfected
patients who received ART based on a protease inhibitor (PI) or nonnucleoside reverse transcriptase inhibitor
(NNRTI) were included. Patients were stratified by ART drug [ATV/rtv, lopinavir (LPV/rtv), efavirenz (EFV),
nevirapine (NVP), and other PIs], HCV genotype (1/4 and 2/3), and IL28B genotype (CC and non-CC). The
Kruskal–Wallis test and chi-squared test were used to compare continuous and categorical variables, respectively. Multivariate analysis consisted of a stepwise linear regression analysis. Six hundred and forty-nine
HIV/HCV-coinfected patients were included. HCV genotype 1/4 patients who received ATV had higher HCV
RNA levels [6.57 (5.9–6.8) log IU/ml] than those who received LPV [6.1 (5.5–6.5) log IU/ml], EFV [6.1 (5.6–6.4)
log IU/ml], NVP [5.8 (5.5–5.9) log IU/ml], or other PIs [6.1 (5.7–6.4) log IU/ml] ( p = 0.014). This association
held for the IL28B genotype (CC versus non-CC). The association was not found in patients carrying HCV
genotypes 2/3. The linear regression model identified the IL28B genotype and ATV use as independent factors
associated with HCV RNA levels. ATV-based therapy may be associated with a higher HCV RNA viral load in
HIV/HCV-coinfected patients.
emoglobin catabolism is closely related to the replication of the hepatitis C virus (HCV).1 Heme oxygenase1 (HO-1) catalyzes the breakdown of the heme molecule to
yield equimolar quantities of biliverdin (BV), iron, and carbon
monoxide. The oxidation of heme by HO-1 releases at least
two antiviral agents, iron and BV.2 Lehman et al. reported that
BV has antiviral activity in replicon cells, noting that antiviral
activity was accompanied by a rise in specific interferonstimulated gene (ISG) products.2 Likewise, Zhu et al. recently
demonstrated that BV has potent antiviral activity against
HCV, with inhibitory action over HCV NS3/4A protease.3
Iron has also been shown to inhibit HCV replication by preventing divalent caption binding to RdRp.4
Atazanavir (ATV) is a protease inhibitor used in HIV therapy. ATV interferes with hemoglobin catabolism because of its
competing inhibitory activity against the uridine diphosphate
glucuronosyltransferase 1A1 (UGT1A1) enzyme, responsible
for bilirubin (BR) conjugation.5 This inhibition is directly
H
1
Unit of Infectious Diseases, Hospital Universitario Reina Sofia, Cordoba, Spain.
Maimonides Institute for Biomedical Research (IMIBIC), Cordoba, Spain.
Unit of Infectious Diseases and Microbiology, Hospital Universitario de Valme, Seville, Spain.
4
Internal Medicine Department, Hospital Universitario de Valme, Seville, Spain.
5
Unit of Infectious Diseases, Hospital Universitario de la Princesa, Madrid, Spain.
6
Unit of Infectious Diseases, Hospitales Universitarios Virgen del Rocio, Seville, Spain.
7
Instituto de Biomedicina de Sevilla (IBIS), Seville, Spain.
8
Unit of Infectious Diseases, Hospital Universitario Puerta del Mar, Cadiz, Spain.
9
Unit of Infectious Diseases, Hospital Universitario Virgen de la Victoria, Malaga, Spain.
10
Internal Medicine Service, Hospital Juan Ramón Jiménez, Huelva, Spain.
11
Unit of Infectious Diseases, Hospital de La Lı́nea de la Concepción, Cádiz, Spain.
12
Immunogenetics Unit, Faculty of Sciences, Universidad de Jaén, Jaen, Spain.
2
3
1
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2
associated with hyperbilirubinemia, the most common side
effect of patients treated with ATV boosted with ritonavir
(ATV/rtv). We hypothesize that this inhibition could modify
the modulatory effect of the products of hemoglobin catabolism on HCV replication.
The aim of this study therefore was to assess the relationship between the use of ATV-based antiretroviral treatment
(ART) and plasma HCV viral load in a population of HIV/
HCV-coinfected patients.
The study population was 829 HCV treatment-naive patients who had been consecutively enrolled from October 2004
to December 2011 in the Spanish HEPAVIR prospective cohort of HIV/HCV-coinfected patients. Further details of these
cohorts have been reported elsewhere.6 Patients who received
ART based on two ITIAN plus a protease inhibitor (PI) or
nonnucleoside reverse transcriptase inhibitors (NNRTI) were
included in the study. Patients who received estavudine, didanosine, or zidovudine were excluded from the study. Only
patients maintained for a minimum of time of 12 months on
an unchanged regimen were included. HCV RNA levels in
plasma were measured using a commercial PCR assay (Cobas
Taqman; Roche Diagnostic Systems Inc., Pleasanton, CA:
detection limit of 50 IU/ml).
Liver fibrosis stage was determined by biopsy or liver
transient elastography (FibroScan, Echosen, Paris). Significant
fibrosis was defined as a METAVIR fibrosis score of F3–F4 in
liver biopsy or a liver stiffness (LS) value of ‡ 8.9. SNP
rs129679860, located 3 kilobases upstream of the IL28B gene,
was genotyped using a custom Taqman assay (Applied Biosystems, Foster City, CA) on DNA isolated from whole blood
samples. The bilirubin data of those patients on ATV/rtv
treatment were also collected. Patients were stratified by ART
drug [ATV/rtv, lopinavir (LPV), efavirenz (EFV), nevirapine
(NVP), or other PI (saquinavir, nelfinavir, darunavir, or indinavir)], HCV genotype (1/4 and 2/3), and IL28B genotype
(CC and non-CC). The Kruskal–Wallis test and chi-squared
test were used to compare continuous and categorical variables, respectively. Post hoc comparisons between groups
were carried out using the Mann–Whitney U test and the chisquared test. To test our hypothesis, we used the Pearson or
the bivariate Spearman’s rank correlation coefficient to analyze the relationship between HCV viral load and bilirubin
levels among patients treated with ATV/rtv. Associations
with p values of < 0.05 were considered significant for comparisons between groups. Multivariate analysis consisted of a
stepwise linear regression analysis.
Six hundred and forty-nine HIV/HCV-coinfected patients
were included in the analysis. Forty patients (7.3%) were
treated with ATV/rtv, 128 (23.4%) with LPV/rtv, 225 (41.2%)
with EFV, 41 (7.5%) with NVP, and 112 (20.5%) received some
other PI. Only nine patients who might have been included in
the analysis and fulfilled the criteria for inclusion in the study
were receiving darunavir/r. Given the low number of patients, we decided not to include them as an independent
group for analysis The most significant characteristics are
T1 c shown in Table 1.
Median HCV RNA levels of HCV genotypes 1/4 and 2/3
were 6.13 (5.6–6.7) log IU/ml and 5.7 (5.3–6.2) log IU/ml,
respectively ( p < 0.001). HCV genotype 1/4 patients who received ATV/rtv had higher HCV RNA levels [6.57 (6.2–6.8)
log IU/ml] than those receiving LPV/rtv [6.1 (5.5–6.5) log
IU/ml], EFV [6.1 (5.6–6.4) log IU/ml], NVP [5.8 (5.5–5.9) log
RIVERO-JUAREZ ET AL.
Table 1. Baseline Population Characteristics
Characteristics
N
Age (years), mean (SD)
Male gender, n (%)
AIDS criteria, n (%)
HbsAg positive, n (%)
Undetectable HIV viral load, n (%)
CD4 cell count (cells/mm3), mean (SD)
HCV genotype 1/4, n (%)
Liver cirrhosis stage, n (%)
IL28B-CC genotype, n (%)a
649
40.8 (5.56)
537 (82.7)
192 (29.6)
8 (1.2)
472 (72.7)
518 (266)
452 (69.6)
154 (23.7)
115 (38.1)
a
Available for 302 patients.
SD, standard deviation; AIDS, acquired immunodeficiency syndrome criteria in the past; HbsAg, hepatitis B surface antigen; IL28B,
interleukin 28B.
IU/ml], or another PI drug [6.1 (5.7–6.4) log IU/ml
( p = 0.014)]. However, this association was not found in
patients bearing HCV genotype 2/3 [ATV/rtv: 5.74 (5.4–5.9)
log IU/ml], LPV/rtv [5.7 (5.2–5.8) log IU/ml], EFV [5.8 (5.6–6)
log IU/ml], NVP [5.3 (4.9–5.5) log IU/ml], and other PI drug
[5.6 (5.4–5.9) log IU/ml, p = 0.34].
The IL28B-CC genotype was associated with a higher HCV
viral load than the non-CC genotype [6.3 (6.2–6.6) log IU/ml
versus 6 (5.9–6.3) log IU/ml, p = 0.001]. There were no differences in HCV viral load found on the basis of detectable
HIV viral load [detectable, 6.1 (5.8–6.4) versus undetectable
6 (5.4–6.2), p = 0.247] or liver fibrosis stage [advanced liver
fibrosis: 6.2 (5.8–6.5) versus absence of liver fibrosis stage: 6.1
(5.9–6.3), p = 0.472]. When HCV RNA viral loads were
analyzed in terms of the drug used for ART, patients with
IL28B-CC receiving ATV/rtv had higher viral loads than
those receiving another drug [ATV/rtv: 7.3 (6.9–7.4) log
IU/ml; LPV/rtv: 6.6 (6.2–6.8) log IU/ml; EFV: 6.6 (6.3–6.8) log
IU/ml; other PI: 6.4 (6.2–6.9) log IU/ml, p = 0.038]. Patients
with IL28B non-CC receiving ATV had higher baseline HCV
viral loads than those receiving another ART regimen [ATV/
rtv: 6.15 (6–6.4) log IU/ml; LPV/rtv: 5.9 (5.8–6.2) log IU/ml;
EFV: 5.8 (5.6–6) log IU/ml; other PIs: 5.9 (5.8–6.1) log IU/ml,
p = 0.032]. The mean ( – SD) bilirubin level among those
patients who received ATV/rtv was 2.31 – 0.87. In these
patients, HCV viral load correlated positively with bilirubin
levels (r = 0.39; p = 0.0129).
Table 2 shows the linear regression model. Independent b T2
factors associated with HCV RNA levels were IL28B genotype
Table 2. Linear Regression Model for Hepatitis C
Virus Baseline Viral Load in Patients Bearing
the Hepatitis C Virus Genotype 1
Variable
IL28B
ATV/rtv
Liver fibrosis stage
HIV viral load
Condition
B
p
CC
Use
Significant
Undetectable
0.7
0.8
0.075
0.18
0.033
0.017
0.884
0.321
R2 = 0.22.
B, adjusted coefficient; IL28B, interleukin 28B; ATV/rtv, atazanavir boosted with ritonavir; HIV, human immunodeficiency virus.
09/28/12
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ATAZANAVIR INCREASES HCV VIRAL LOAD
(B = 2.7; p = 0.033) and use of ATV (B = 2.8; p = 0.017). R2 was
0.22.
This is the first study to show the association between
ATV/rtv use and HCV RNA viral load. Since a high HCV
RNA viral load is a risk factor for nonresponse to treatment,
this may be an important issue in conditioning the response to
pegylated-interferon (PEG-IFN) with ribavirin (PEG-IFN/
RBV) or to therapy based on NS3 protease inhibitors in HIV/
HCV genotype 1-coinfected patients.7–9 However, the relationship between ATV/rtv and treatment response has not
yet been analyzed.
The reason ATV use might be associated with higher HCV
RNA viral loads is unknown. In vitro studies have reported
that BR and BV show antiviral activity against HIV, the herpes
virus, and HCV.3 More specifically, the antiviral action
against HCV is due to both recombinant and endogenous
NS3/4A protease from replicon microsomes being inhibited
by BR and BV.3 HO-1, on the other hand, potentiates interferon (IFN)-a, and so enhances antiviral activity.2 Hyperbilirubinemia and ATV use are directly associated because of
ATV’s competing inhibitory activity against UGT1A1, responsible for BR conjugation in the liver. Inhibition may
modify hemoglobin catabolism by suppressing various enzymes with antiviral activity against HCV (BR-R, BV-S, and
HO-1) due to the enhancement of the resulting metabolite
(BR) or reduced ISG activity (from the inhibition or downregulation of HO-1). There is no evidence that ATV blocks the
activity of HO-1, in addition to inhibiting UGT1A1. However,
a clinical trial is currently in progress whose secondary objective is to determine the effect of atazanavir-induced hyperbilirubinemia on HO-1 induction (NCT00916448), which
may clarify this question. On the other hand, our study
showed that NVP use was associated with lower HCV viral
load, as has previously been reported by our group.10
Our study has several limitations. First, the number of
patients with ATV-based therapy was relatively low. Second,
the design was not a randomized study, which may have led
to bias not being recognized. Third, no concomitant drugs
were considered in the analysis. Fourth, although BR is closely
related to ATV/rtv use, BR levels were not collected. Fifth, no
concomitant diseases were analyzed in our study, and it is
known that several liver pathologies may condition BR levels,
as Gilbert’s syndrome.
In conclusion, on the basis of our results, ATV-based therapy may be associated with higher HCV RNA viral loads
among HIV/HCV-coinfected patients, a finding that could
have an important impact on the outcome of HCV therapy.
Studies are needed to confirm the relationship found in our
study, as well to analyze this association in HCV treatment
response.
3
recipient of an extension grant from the Instituto de Salud
Carlos III (Programa-I3SNS).
Author Disclosure Statement
The authors have received consulting fees from BristolMyers Squibb, Abbott, Gilead, Roche, and Boehringer
Ingelheim. They have received research support from GlaxoSmithKline, Roche, Bristol-Myers Squibb, Schering-Plough,
Abbott, and Boehringer Ingelheim and lecture fees from
GlaxoSmithKline, Roche, Abbott, Bristol-Myers Squibb,
b AU1
Boehringer Ingelheim, and Schering-Plough.
References
1. Choi J and Ou JHJ: Mechanism of liver injury. III. Oxidative
stress in the pathogenesis of hepatitis C virus. Am J Physiol
Gastrointest Liver Physiol 2006;290:G847–851.
2. Lehmann E, EL-Tantawy WH, Ocker M, et al.: The heme
oxygenase 1 product biliverdin interferes with hepatitis C
virus replication by increasing antiviral interferon response.
Hepatology 2010;51:398–404.
3. Zhu Z, Wilson AT, Luxon BA, et al.: Biliverdin inhibits
hepatitis C virus NS3/4A protease activity: Mechanism for
the antiviral effects of heme oxygenase? Hepatology 2010;52:
1897–1905.
4. Fillebeen C, Rivas-Estilla AM, Bisaillon M, et al.: Iron inactivates the RNA polymerase NS5B and suppresses subgenomic replication of hepatitis C virus. J Biol Chem 2005;
280:9049–9057.
5. Brierly C and Burchell B: Human UDP-glucoronosyl transferases: Chemical defence, jaundice and gene therapy.
Bioessays 1993;15:749–754.
6. Neukam K, Mira JA, Ruiz-Morales J, et al.: Liver toxicity
associated with antiretroviral therapy including efavirenz or
ritonavir-boosted protease inhibitors in a cohort of HIV/
hepatitis C virus co-infected patients. J Antimicrob Chemother 2011;66:2605–2614.
7. Dore GJ, Torriani FJ, Rodriguez-Torres M, et al.: Baseline
factors prognostic of sustained virological response in
patients with HIV-hepatitis C virus co-infection. AIDS 2007;
21:1555–1559.
8. Poordad F, McCone J, Bacon BR, et al.: Boceprevir for untreated chronic HCV genotype 1 infection. N Engl J Med
2011;364:1195–1206.
9. Jaconson IM, Mchutchison JG, Dusheiko G, et al.: Telaprevir
for previously untreated chronic hepatitis C virus infection.
N Engl J Med 2011;364;25:2405–2416.
10. Mata RC, Mira JA, Rivero A, et al.: Nevirapine-based antiretroviral therapy is associated with lower plasma hepatitis
C virus viral load among HIV/hepatitis C virus-coinfected
patients. J AIDS Clinic Res 2010;1:110.
Acknowledgments
This work was partly supported by grants from the Fundación Progreso y Salud, Consejerı́a de Salud de la Junta de
Andalucı́a (grants for health research projects: 0036/2010, PI0247-2010, PI-0208, and 0124/2008) and the Spanish Health
Ministry (ISCIII-RETIC RD06/006 and projects PI10/0164
and PI10/01232). A.R. is the recipient of a research extension
grant from the Fundación Progreso y Salud, Consejerı́a de
Salud de la Junta de Andalucı́a (AI-0011-2010); J.A.P. is the
Address correspondence to:
Antonio Rivero
Hospital Universitario Reina Sofia de Córdoba
Edificio Provincial
Hospital de dı́a de Enfermedades Infecciosas
Avd. Menendez Pidal s/n
14004 Cordoba, Spain
E-mail: [email protected]
DISCUSIÓN:
Los trabajos científicos presentados en esta memoria se diseñaron para
mejorar el conocimiento y la práctica clínica habitual en el tratamiento del
paciente coinfectado por el VIH/VHC. Los resultados obtenidos en los
trabajos presentados nos permiten realizar algunas consideraciones
generales y específicas sobre la predicción de la respuesta al tratamiento
con IFN-Peg/RBV en el paciente coinfectado por el VIH/VHC. Los
estudios realizados se agrupan en:
1. Bloque I: Predicción de respuesta al tratamiento tras la finalización
del mismo: evaluación del valor predictivo positivo sobre RVS de la
semana 12 tras finalización del tratamiento.
2. Bloque II: Evaluación de la influencia de los factores genéticos
IL28B (rs129679860) y LDLr (rs14158) en la respuesta al
tratamiento mediante el estudio de la cinética viral durante las
primeras semanas del mismo.
3. Bloque III: Evaluación de la respuesta al tratamiento del VHC
genotipo 3 con distintas dosis de IFN-Peg/RBV mediante el estudio
de la cinética viral durante las primeras semanas del mismo.
4. Bloque IV: Estudios sobre factores basales predictivos de respuesta
al tratamiento.
Nota: las referencias bibliográficas citadas en cada uno de los bloques se
corresponde a las referenciadas en la sección References del final de cada
trabajo presentado.
Bloque I: Predicción de respuesta al tratamiento tras la finalización del
mismo: evaluación del valor predictivo positivo sobre RVS de la
semana 12 tras finalización del tratamiento.
Los resultados presentados en este estudio muestran que la
determinación de la carga viral del VHC en la semana 12 tras finalización
del tratamiento (W12), mediante una técnica sensible con un límite mínimo
de detección de 15 UI/mL, puede ser considerada como un punto apropiado
para evaluar RVS y recidivas en pacientes coinfectados por el VIH/VHC.
Como ocurre en el caso de los pacientes monoinfectados, alcanzar
carga viral indetectable en semana 24 tras finalización del tratamiento, es el
principal objetivo del tratamiento frente al VHC en pacientes coinfectados
por el VIH [8]. Sin embargo, estudios realizados en población
monoinfectada por el VHC han identificado la W12 tras finalización del
tratamiento como un punto apropiado para valorar RVS [5, 6, 9]. MartinotPeignoux et al, evaluaron en una población de 573 pacientes
monoinfectados por el VHC tratados con IFN-Peg/RBV y que alcanzaron
RFT el valor predictivo positivo de la determinación de la W12 sobre RVS
usando un límite mínimo de detección de 5-10 UI/mL [6]. En la W12, 409
pacientes permanecieron con carga viral indetectable, de los que 408
alcanzaron RVS (VPP: 99,7%; IC 95%: 99,1-100%), concluyendo que la
determinación de este punto es igual de significativa que la determinación
en la semana 24 para valorar RVS. Por otro lado, Aghemo et al, obtuvieron
similares resultados (VPP= 100%) usando dos técnicas diferentes con unos
límites mínimos de detección de 15 UI/mL y 50 UI/mL, en 32 y 258
pacientes respectivamente [9]. En nuestro estudio, usando un límite mínimo
de detección de 15 kUI/mL, ninguna recidiva se produjo después de la
W12, teniendo una VPP para RVS del 100%.
La cadencia de la recidiva del VHC en el paciente coinfectado por el
VIH ha sido poco estudiada. En un estudio llevado a cabo en 143 pacientes
coinfectados por el VIH tratados con IFN-Peg/RBV que alcanzaron RFT,
todas las recidivas menos 2 (45/47; 95,7%) se produjeron antes de la W12
[7]. Análisis filogenéticos del virus en estos pacientes sugieren que en uno
de ellos se produjo una reinfección por otro virus (diferente genotipo), y
que el segundo paciente tuvo contacto con el mismo virus que le produjo la
primoinfección. Nuestro estudio sugiere que la propia infección por el VIH
no aumenta el riesgo de VR del VHC después de la W12.
El conocimiento precoz del estatus post-tratamiento del paciente
puede tener un efecto beneficioso sobre el manejo del paciente tratado
frente al VHC. De manera que, reducir el periodo de seguimiento en 12
semanas respecto a las 24 semanas estándares, podría reducir los costes
asociados a la monitorización de la respuesta al tratamiento, mejorar el
cuidado del paciente y detectar de forma precoz las recidivas,y así,
implementar de forma precoz alternativas terapéuticas. No obstante, el
valor predictivo de la W12 sobre RVS solo se ha evaluado en pacientes que
inician un primer tratamiento con IFN-Peg/RBV. Por ello, sería necesario
evaluar este marcador de respuesta en pacientes que han fracasado a una
terapia anterior.
Bloque II: Evaluación de la influencia de los factores genéticos IL28B
(rs129679860) y LDLr (rs14158) en la respuesta al tratamiento
mediante el estudio de la cinética viral durante las primeras semanas
del mismo.
Efecto de IL28B (rs129679860)
Se analizó el efecto de las variaciones genotípicas de IL28B en una
cohorte de 119 pacientes coinfectados por el VIH/VHC sin restricciones de
genotipos. En este estudio se observó que las variaciones en el genotipo de
IL28B son un potente marcador predictivo pre-tratamiento del descenso
viral del VHC durante el tratamiento con IFN-Peg/RBV en pacientes
coinfectados por el VIH y genotipos 1/4 del VHC. De forma que los
pacientes con genotipo CC de IL28B (definido como favorable) tienen un
descenso en la carga viral del VHC mayor que los pacientes con genotipo
CT oTT (No-CC) de IL28B. Este efecto se observa tan precozmente como
en la semana 1 tras inicio de la terapia, y se mantiene hasta la semana 4,
aumentando las tasas de RVR.
En nuestro estudio no se observaron diferencias entre los diferentes
genotipos de IL28B en el descenso viral del VHC, ni en las tasas de RVR,
entre pacientes infectados por genotipo 3. No obstante, debido a que los
pacientes con genotipo 3 tienen un alto decline viral y tasas de RVR, sería
necesario una cohorte mayor para poder encontrar estas diferencias.
La cinética viral del VHC durante el tratamiento con IFN es bifásica.
La primera fase, en la que se produce un aclaramiento rápido del virus,
tiene lugar durante las primeras 72h de tratamiento y está relacionada con
la eliminación de los virones libres y la inhibición de la producción de
nuevos virus [7]. La segunda fase es más lenta y prolongada y está
relacionada con la eliminación de las células infectada por VHC.
Stättermayer et al evaluaron el descenso viral del VHC durante las
primeras 24h de tratamiento, observando que los pacientes con genotipo
CC de IL28B tuvieron un mayor descenso que los pacientes con genotipo
no-CC de IL28B [5]. En otro estudio, Thompson et al, detectaron
diferencias entre los genotipos de IL28B desde la 2 semana de tratamiento,
punto más precoz analizado [4]. En nuestro estudio encontramos
diferencias significativas entre los genotipos de IL28B entre el momento
basal y semana 1 en pacientes coinfectados por VHC genotipo 1. Sin
embargo no encontramos diferencias en la cinética viral entre las semanas
1-2 ni entre la 2-4. Este es un hallazgo importante, ya que implica que el
efecto de IL28B se produciría durante la primera fase de la cinética viral.
Esta aclaramiento mas rápido del VHC incrementaría a su vez las tasas de
RVR, que ha demostrado ser el mayor factor predictivo de RVS.
Efecto de LDLr (rs14158)
El VHC tiene una estrecha relación con el metabolismo lipídico del
hospedador [15]. LDLr es un receptor fundamental en la entrada del virus
en el hepatocito, por lo tanto, las variaciones genéticas de este receptor
pueden condicionar la ciclo replicativo del virus. Este hecho queda patente
en otros estudios publicados por nuestro grupo de investigación en el que
se observa que los pacientes con genotipo CC de LDLr (favorable) tienen
una carga viral basal menor que los que pacientes con genotipo TT o CT
(no-CC) [13]. En nuestro estudio encontramos diferencias significativas en
el descenso viral del VHC durante las primeras semanas de tratamiento con
IFN-Peg/RBV entre genotipos de LDLr. Esta diferencia solo se encontró
entre el momento basal y la semana 1, aspecto que sugiere que este
marcador, al igual que IL28B, influye en la primera fase de la cinética viral
del VHC.
Por otro lado, nuestro estudio muestra que los pacientes con genotipo
CC de IL28B, solo presentan un impacto positivo en la cinética viral del
VHC durante las primeras de tratamiento si son portadores del genotipo CC
de LDLr. Este efecto sinérgico entre IL28B/LDLr provoca un mayor
aclaramiento del VHC durante las primeras semans del tratamiento y
aumento del porcentaje de pacientes que alcanzan RVR. De esta forma los
pacientes con genotipo CC de IL28B que no portaban genotipo CC de
LDLr mostraron un descenso viral similar a los pacientes con genotipo noCC de IL28B. Este hallazgo es importante, ya que sugiere que el efecto de
IL28B en la cinética viral precoz solo se produce en presencia de un
genotipo concreto de LDLr. Si esto fuese confirmado por otros estudios
sería de gran importancia clínica, ya que la simple determinación de IL28B,
sin la determinación del genotipo de LDLr, en la toma de decisiones
clínicas en el tratamiento del VHC, tendría un papel limitado.
Efecto de IL28B (rs129679860) en los genotipos 1a y 1b del VHC
Se ha descrito que los pacientes infectados por genotipo 1b del VHC tienen
unas tasas de respuesta al tratamiento con IFN-Peg/RBV superiores a los
pacientes infectados por genotipo 1a [20, 24]. La causa sin embargo es
desconocida. En base a nuestros resultados la mayor tasa de respuesta
observada en pacientes infectados por genotipo 1b puede ser debida a que
el genotipo CC de IL28B tiene un mayor efecto en este genotipo que en el
genotipo 1a. La razón es desconocida. Se ha descrito que ciertas
mutaciones tanto en las proteínas estructurales como no estructurales del
VHC tienen la capacidad de modular la respuesta al tratamiento [25, 26]. El
mecanismo por el cual se asocian estas mutaciones con una mayor o menor
tasa de respuesta al tratamiento está relacionado con la sensibilidad del
virus a IFN [27, 28]. De manera que, aquellos pacientes con la mutación
del core 70R muestran unas mayores tasas de RVS que aquellos pacientes
con la mutación 70Q [29, 30]. Del mismo modo, se han identificado varias
mutaciones en la proteína NS5A relacionadas con unas mayores o menores
tasas de RVS [27]. Estas mutaciones favorables son más frecuentes en el
genotipo 1b del VHC [21], por lo tanto la mayor tasa de respuesta
tratamiento con IFN-Peg/RBV observada en pacientes con genotipo 1b
puede ser debido a este mecanismo. Por otro lado, las variaciones en el
genotipo de IL28B han sido relacionadas con una mayor (IL28B no-CC) o
menor ( IL28B-CC) actividad endógena de IFN-lambda [31]; por ello es de
esperar que en pacientes con una menor actividad de IFN endógeno, se
produzca un mayor aclaramiento viral cuando IFN exógeno es
administrado. Por ello, se podría especular que los pacientes mas sensibles
al IFN (IL28B-CC) infectados por un virus más sensible al IFN (genotipo
1b) tendrían unas tasas mayores de respuesta al tratamiento. No obstante,
este punto no deja de ser una hipótesis, debido a que en nuestro estudio no
se han determinado las mutaciones virales asociadas con la sensibilidad al
IFN.
Bloque III: Evaluación de la respuesta al tratamiento de distintas dosis
de IFN-Peg/RBV mediante el estudio de la cinética viral del VHC
genotipo 3 durante las primeras semanas del mismo.
En nuestro estudio la dosis administrada de IFN-Peg/RBV resultó ser
el factor más influyente en el descenso viral del VHC durante las primeras
semanas de tratamiento en pacientes coinfectados por el VIH y genotipo 3
del VHC. Este diferencia en el descenso viral durante las primeras semanas
de tratamiento provocó a su vez que las tasas de RVR entre los pacientes
que recibieron dosis estándar de tratamiento (SDG; 72,9%) fuera superior a
la de los que recibieron dosis baja de tratamiento (LDG; 59,6%). Estas
diferencias
no
alcanzaron
significación
estadística
(p
=0,174),
probablemente porque las altas tasas de RVR alcanzadas por los pacientes
infectados por genotipo 3 del VHC, podrían hacer necesaria una población
de estudio mayor.
El empleo de dosis bajas de tratamiento es una práctica habitual en
pacientes monoinfectados por el VHC genotipo 3, debido a que ha sido
demostrada su no inferioridad en las tasas de RVR y RVS frente a dosis
estándar de tratamiento en varios ensayos clínicos [9, 10, 22-24]. En
pacientes coinfectados por el VIH, el empleo de dosis más bajas de
tratamiento podría ser de utilidad ya que podría condicionar un menor coste
del tratamiento y una menor incidencia de efectos adversos. No obstante, al
contrario de lo ocurre en población monoinfectada por el VHC, no existen
ensayos clínicos aleatorizados que avalen el empleo de dosis más bajas de
tratamiento en la población coinfectada por el VIH. Un ensayo clínico
piloto de una sola rama de tratamiento en el que se incluyeron 58 pacientes
coinfectados por el VIH y genotipo 3 del VHC tratados con dosis bajas de
IFN-Peg/RBV obtuvo unas tasas de RVS del 58.3% (análisis por intención
de tratar) [20]. En base a esta tasa de respuesta, se ha sugerido que dosis
bajas de tratamiento podrían tener una efectividad similar a la obtenida con
el uso de dosis estándar. Sin embargo, nuestros resultados muestran
diferencias en la cinética viral y en las tasas de RVR con el empleo de dosis
bajas y estándar de tratamiento. Por ello, hasta que se lleve a cabo un
ensayo clínico aleatorizado que compare la eficacia y seguridad de ambas
dosis de tratamiento, debe tenerse precaución en el uso de dosis bajas de
tratamiento en pacientes coinfectados por el VIH y genotipo 3 del VHC.
Por otro lado, nuestro estudio no encontró asociación entre el
genotipo de IL28B y el descenso viral del VHC durante las primeras
semanas de inicio de la terapia en ambos grupos de tratamiento. Esta
observación confirma los resultados obtenidos en el primer estudio
presentado en el bloque II.
Bloque IV: Estudios sobre factores basales predictivos de respuesta al
tratamiento.
Factores basales asociados a VR del VHC en pacientes tratados con IFNPeg/RBV coinfectados por el VIH
Nuestro estudio identifica factores basales asociados a VR del VHC
en una cohorte de 212 pacientes tratados con IFN-Peg/RBV. Los factores
identificados fueron el presentar una carga viral alta (> 600.000 UI/mL), un
índice de masa corporal (IMC) ≥25 kg/m2, estar infectado por genotipos 1
ó 4, presentar un grado F3-F4 de fibrosis hepática (en base a la escala
METAVIR) y el haber desarrollado previamente un evento definitorio de
Síndrome de Inmunodeficiencia Humana Adquirida (SIDA).
Tanto el grado fibrosis hepática, la carga viral basal alta como el
índice de masa corporal han sido identificados previamente en estudios
realizados en pacientes monoinfectados por el VHC [7, 13-24]. Sin
embargo la identificación del desarrollo de criterio de SIDA como factor
asociado a VR no había sido observada previamente. La causa de esta
asociación es desconocida. Una hipótesis que podría explicar este hallazgo
sería la posible pérdida de la inmunidad asociada al aclaramiento del VHC
en los pacientes con criterio de SIDA. Esta hipótesis permitiría también
explicar las mayores tasas de VR observadas en pacientes coinfectados por
el VIH en relación a los pacientes monoinfectados por el VHC.
Por otro lado, nuestro estudio no identificó las variaciones en los
genotipos de IL28B y de LDLr como factores asociados a VR en pacientes
coinfectados por el VIH.
Influencia de los fármacos integrantes del ART en la carga viral basal
del VHC
En nuestro estudio el uso de ATV como parte del TAR del paciente
coinfectado por el VIH y genotipo 1 ó 4 del VHC se asoció a unamayor
carga viral del basal VHC respecto a otros ART.
La causa de este efecto es desconocida. ATV es un inhibidor de la
proteasa del VIH que interfiere en el catabolismo de la hemoglobina
mediante la inhibición de la enzima UGT1A1, responsable de la
conjugación de la bilirrubina (BR) [5]. Esta inhibición se asocia a
hiperbilirrubinemia; el efecto mas común asociado a ATV. Estudios invitro han comprobado que tanto BR como Biliverdina (BV), un metabolito
del grupo hemo, tienen efecto antiviral directo frente al VIH y VHC [3].
Específicamente este efecto antiviral se debe a una inhibición de la proteína
NS3/4a del VHC. Por otra parte, la hemo-oxigenasa, enzima encargada de
la oxidación del grupo hemo, potencia la producción de IFN, por lo que
aumenta la actividad antiviral [2]. Por ello, la interferencia en el
catabolismo del grupo hemo, por parte de ATV podría disminuir el efecto
antiviral asociado a los catabolitos resultantes y por lo tanto asociarse a una
mayor carga viral.
El presentar una carga viral alta es un factor asociado tanto a baja
respuesta al tratamiento, como a un mayor riesgo de VR del VHC [7-9].
Por ello, este hallazgo podría tener una importante repercusión clínica en la
práctica clínica del paciente coinfectado por el VIH y VHC. Serían
necesarios nuevos estudios que evaluasen la posible influencia de esta
asociación en la respuesta al tratamiento.
CONSLUSIONES
1. Undetectable HCV RNA at W12 post-treatment has a high PPV
for SVR. Testing for HCV RNA at this moment may therefore be
considered an appropriate point in time for identifying SVR and
relapse in HIV/HCV co-infected patients receiving treatment with
Peg-INF/RBV.
2. The IL28B (rs12129679860) genotype impacts on viral kinetics
during the first week of treatment with Peg-IFN/RBV in patients
with HCV genotype 1 or 4 co-infected with HIV.
3. The IL28B (rs12129679860) genotype has not impact on viral
kinetics during the first week of treatment with Peg-IFN/RBV in
patients with HCV genotype 3 co-infected with HIV.
4. The fastest reductions in viral load observed in IL28B-CC
patients correlated with increased rates of RVR in HIV/HCV
genotype 1 or 4 co-infected patients.
5. The LDLr (rs14158) genotype impacts on HCV viral kinetics
during the first days of starting treatment with Peg-IFN/RBV in
HIV/HCV genotype 1 co-infected patients
6. Both IL28B and LDLr CC genotype have a synergistic effect on
HCV viral decline during first weeks after starting treatment with
Peg-IFN/RBV and RVR rate in HIV/HCV genotype 1 co-infected
patients.
7. The IL28B-CC genotype had a positive effect on HCV viral
clearance during the first weeks of treatment with Peg-IFN/RBV
and on RVR rates in HCV-1b genotype HIV co-infected patients,
but not those with HCV-1a
8. HCV viral decline was less for patients in the low-dose group
compared to those receiving the standard dose. Until a
randomized clinical trial is conducted, clinicians should be
cautious about using lower doses of Peg-IFN/RBV in HIV/HCV
genotype 3 co-infected patients.
9. The IL28B-CC genotype (rs12129679860) does not have a
positive impact on HCV viral decline in the first weeks after start
of therapy using a lower drug doses in HIV/HCV co-infected
patients.
10. Significant liver fibrosis, high baseline serum HCV RNA, AIDSdefining criteria in the past, BMI >25 kg/m2 and HCV genotypes
1 or 4 are factors associated with VR.
11. ATV-based therapy is associated with a higher HCV RNA viral
load in HIV/HCV-genotype 1 co-infected patients.
ANEXO
I:
OTRAS
PUBLICACIONES
DERIVADAS
DEL
TRABAJO DEL DOCTORANDO
1.- Macias J, del Valle J, Rivero A, Mira JA, Camacho A, Merchante N,
Perez-Camacho I, Neukam K, Rivero-Juarez A, Mata R, Torre-Cisneros J,
Pineda JA. Changes in liver Stiffness in patients with Chronic hepatitis C
with and without HIV co-infection treated with pegylated interferon plus
ribavirin. Journal of Antimicrobial Chemotherapy. 2010; 65: 2204-11.IF
(JCR) 4,659
2.- Perez-Camacho I, Rivero-Juarez A, Kindelan JM, Rivero A. Presentday treatment of tuberculosis and latent tuberculosis infection (review).
Enfermedades Infecciosas y Microbiología Clínica. 2011; Supple 1: 41-6.
IF (JCR): 1,656.
3.- Pineda JA, Caruz A, Di Lello FA, Camacho A, Mesa P, Neukam K,
Rivero-Juarez A, Macias J, Gomez-Mateo J, Rivero A. Low-density
lipoprotein receptor genotyping enchances the predictive value of IL28B
genotype in HIV/hepatitis C virus coinfected patients. AIDS. 2011; 25:
1415-20. IF (JCR) 6.348.
4.- Neukam K. Rivero-Juarez A, Caruz A, DiLello FA, Torre-Cisneros J,
Lopez-Biedma A, Cifuentes C, Camacho A, Garcia-Rey S, Rivero A,
Pineda JA. Influence of the combination of low-density liporpotein
receptor and interleukin 28B genotypes on lipid plasma levels in
HIV/hepatitis C-coinfected patients. Journal of Accquire Immune Defic
Syndr. 2011; 58: 115-7. IF (JCR) 4,262.
5.- Merchante N. Rivero-Juarez A. Tellez F. Merino D. Rios Villegas MJ.
Marquez-Solero M. Omar M. Macias J. Camacho A. Perez-perez M.
Gomez-Mateos J. Rivero A. Pineda JA. Liver stiffness predicts clinical
outcome in HIV/HCV-coinfected patients with compensated liver cirrosis.
Hepatology. 2012; 56: 228-238. IF (JCR) 11,665.
6.- Recio E. Macias J. Rivero-Juarez A. Tellez F. Merino D. Rios M.
Marquez M. Omar M. Rivero A. Lorenzo S. Merchante N. Pineda JA.
Liver stiffness correlates with Child-Pugh-Turcotte and MELD scores in
HIV/hepatitis
C
virus
coinfected
patients
with
cirrhosis.
Liver
International. 2012; 32: 1031-2. IF (JCR) 3.824
7.- Mira JA. Rivero A. de los Santos-Gil I. Lopez-Cortes LF. GironGonzalez JA. Marquez-Solero M. Merino D. Del mar Viloria M. Tellez F.
Rios-Villegas MJ. Omar M. Rivero-Juarez A. Pineda JA. Hepatitis C
virus genotype 4 responds better to pegylated inteferon plus ribavirin tan
genotype 1 in hiv-infected patients. AIDS. 2012; 26:1721-4. IF (JCR)
6,348.
8.- Rivero-Juarez A. Morgaz J. Camacho A. Muñoz-Rascon P.
Dominguez JM. Sanchez-Cespedes R. Torre-Cisneros J. Rivero A. Liver
stiffness using transient elastography is applicable to canines for hepatic
disease models. Plos ONE. 2012; 7: e41557. IF (JCR) 4.441
9.-Mira JA, García-Rey S, Rivero A, de Los Santos-Gil I, López-Cortés
LF, Girón-González JA, Téllez F, Márquez M, Merino D, Ríos-Villegas
MJ, Macías J, Rivero-Juárez A, Pineda JA. Response to Pegylated
Interferon Plus Ribavirin Among HIV/Hepatitis C Virus-Coinfected
Patients With Compensated Liver Cirrhosis. Clinical Infectious Diseases.
2012; 55: 1719-26. IF (JCR) 9.154
10.- Neukam K, Almeida C, Caruz A, Rivero-Juárez A, Rallón N, Di
Lello F, Herrero R, Camacho A, Benito J, Macias J, Rivero A, Soriano V,
Pineda JA. A model to predict the response to therapy against hepatitis C
virus (HCV) including low-density lipoprotein receptor genotype in
HIV/HCV-coinfected patients. Journal of Antimicrobial Chemotherapy.
2012; In press. IF (JCR): 5,068
11.- Mira JA, Rivero-Juarez A, Lopez-Cortes LF, Giron-Gonzalez JA,
Tellez F, Santos-Gil I, Macias J, Merino D, Marquez M, Rios-Villegas MJ,
Gea I, Merchante N, Rivero A, Torres-Cornejo A, Pineda JA. Benefits
from sustained virological response to pegylated interferón plus ribavirin in
HIV/HCV-coinfected
patients
with
compensated
Infectious Diseases. 2013; In press. IF (JCR): 9.154
cirrosis.
Clinical
ANEXO II: ESTANCIAS EN CENTROS INTERNACIONALES
DERIVADAS DEL PROYECTO DE TESIS DOCTORAL
Centro: Food and Drugs Administration (FDA). National Institutes of
Health (NIH). Laboratory of Molecular and Developmental Immunology.
Division of mononuclear antibodies. Bethesda. Maryland. USA.
Duración: 3 meses. (Octubre-Diciembre 2012)
Responsable:M.D./PhD. Francisco Borrego
Contacto:[email protected]
Dirección: 29 Lincoln Drive, Building 29B, Room 3NN04. Bethesda, MD,
20892.
ANEXO III: PREMIOS DE INVESTIGACION CONSEGUIDOS
POR EL DOCTORANDO
1.- Premio Salud Investiga 2010 en la modalidad Alianzas y Cooperación
de la Consejería de Salud de la Junta de Andalucía, como integrante del
Grupo para el estudio de las hepatitis víricas (HEPAVIR) de la sociedad
andaluza de enfermedades infecciosas (SAEI).
2.- “Young investigator award” en el 19th Conference on Retroviruses and
Opportunistics infections (CROI). 5-8 March, 2012 Seattle (USA).
3.- Premio a la mejor comunicación en tema Tratamiento en el XIII
Congreso Nacional Sobre SIDA (SEISIDA), Santiago de Compostela. 1618 de Julio 2010.
4.- Premio a la mejor comunicación en tema Ciencias Básicas en el XIV
Congreso Nacional Sobre SIDA (SEISIDA) Zaragoza, 15-17 de Junio
2011.
5.- Premio a la mejor comunicación en tema Clínica en el XIV Congreso
Nacional Sobre SIDA (SEISIDA) Zaragoza, 15-17 de Junio 2011.
6.- Premio a la mejor comunicación en tema Tratamiento en el XIV
Congreso Nacional Sobre SIDA (SEISIDA) Zaragoza, 15-17 de Junio
2011.
ANEXO
IV:
PROYECTOS
CONVOCATORIA
PÚBLICA
FINANCIADOS
COMO
MEDIANTE
INVESTIGADOR
PRINCIPAL DERIVADOS DEL PROYECTO DE TESIS
Título: Influencia de los receptores killer immunoglobulin-like receptors
(KIRs) de las células Natural Killer en la respuesta al tratamiento del VHC
en pacientes coinfectados por el VIH/VHC.
Investigadores Colaboradores: Antonio Rivero Román, José Peña
Martínez, Ángela Camacho Espejo, Inés Pérez Camacho.
Entidad Financiadora: Consejería de Salud de la Junta de Andalucía.
Anualidades: 3 (2013-2015)
Código: 0430-2012
ANEXO
V:
CAPITULOS
DE
LIBROS
DERIVADOS
DEL
PROYECTO DE TESIS DOCTORAL
1.- Coinfección por VIH y VHC. Capitulo 1: Estructura genómica y ciclo
biológico del VHC. (Rivero A, Pineda JA Eds. Málaga 2012: 19-26.ISBN:
978-84-695-4272-9)
2.- Coinfección por VIH y VHC. Capítulo 5: Trastornos metabólicos
asociados a la hepatitis C: esteatosis, dislipidemias, alteraciones glucídicas
y alteraciones metabólicas. (Rivero A, Pineda JA Eds. Málaga 2012: 53-62.
ISBN: 978-84-695-4272-9)
3.- Coinfección por VIH y VHC. Capítulo 13: Tratamiento de la hepatitis C
por genotipo 1: fármacos, pautas y reglas de parada. (Rivero A, Pineda JA
Eds. Málaga 2012: 137-146. ISBN: 978-84-695-4272-9)
ANEXO VI: PATENTE DERIVADA DEL PROYECTO DE TESIS
DOCTORAL
Título: Método de obtención de datos útiles para predecir la respuesta al
tratamiento de la Hepatitis C.
Autores: José Peña Martínez. Rafael González Fernández. Antonio Rivero
Román. Bárbara Manzanares Martín. Antonio Rivero Juárez. Ángela
Camacho Espejo. Julián Torre Cisneros. (Propiedad intelectual a partes
iguales).
Nº solicitud: P201232061
Referencia: UCO-FIBICO-72
Fecha de prioridad: 28 diciembre 2012, 12:48 (CET)
Entidad titular: Universidad de Córdoba compartida con Instituto
Maimonides de Investigación Biomédica de Córdoba (IMIBIC).
País: España

FACTORES PREDICTIVOS DE RESPUESTA AL TRATAMIENTO

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